ptsd resolution5.2
DESCRIPTION
This presentation explains the background to the current definition of PTSD as it still stands in 2011 and the NICE guideline current treatment recommendations. It then considers some controversy in the field amongst the researchers regarding the lack of effect differences between different treatments and finishes with pragmatic suggestions about future direction.TRANSCRIPT
PTSD research and statistics
Bill Andrews
Pragmatic Research Network
1Sunday, 6 February 2011
Bill Andrews
Pragmatic Research Network
PTSD treatment: the facts; outcomes of therapy
1Sunday, 6 February 2011
Bill AndrewsResearch Coordinator
Pragmatic Research Network
2Sunday, 6 February 2011
The HGIPRN is expanding now to inclue and encourage a wider audience. The HGIPRN will forma sub-set of the total number of data contributors.
Bill AndrewsSenior advisor
ICCEwww.centerforclinicalexcellence.com
3Sunday, 6 February 2011
The ICCE is a great resource.
What is PTSD? 1/6
DSM-IV-TR, APA, 2000
4Sunday, 6 February 2011
What is PTSD? 1/6
• A: An event(s), witnessed, experienced or confronted by; actual or threatened death of physical injury, or physical integrity of others AND the individual’s response was of intense fear, helplessness or horror
DSM-IV-TR, APA, 2000
4Sunday, 6 February 2011
What is PTSD? 2/6
DSM-IV-TR, APA, 2000
5Sunday, 6 February 2011
What is PTSD? 2/6
• B: The event(s) is re-expereinced in the form of intrusive thoughts, distressing dreams, and/or a feeling that the event is reoccurring
DSM-IV-TR, APA, 2000
5Sunday, 6 February 2011
What is PTSD? 3/6
DSM-IV-TR, APA, 2000
6Sunday, 6 February 2011
What is PTSD? 3/6
• C: Persistent avoidance of stimuli associated with the event(s)
DSM-IV-TR, APA, 2000
6Sunday, 6 February 2011
What is PTSD? 4/6
DSM-IV-TR, APA, 2000
7Sunday, 6 February 2011
What is PTSD? 4/6
• D: Elevated arousal that was NOT present prior to the event(s)
DSM-IV-TR, APA, 2000
7Sunday, 6 February 2011
What is PTSD? 5/6
DSM-IV-TR, APA, 2000
8Sunday, 6 February 2011
What is PTSD? 5/6
• E: The symptoms must persist for more than 1 month
DSM-IV-TR, APA, 2000
8Sunday, 6 February 2011
What is PTSD? 6/6
DSM-IV-TR, APA, 2000
9Sunday, 6 February 2011
What is PTSD? 6/6
• F: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
DSM-IV-TR, APA, 2000
9Sunday, 6 February 2011
Psychological Trauma
10Sunday, 6 February 2011
It’s easier to understand trauma on a continuum.
Psychological Trauma
continuum
10Sunday, 6 February 2011
It’s easier to understand trauma on a continuum.
Psychological Trauma
physiological arousal
continuum
10Sunday, 6 February 2011
It’s easier to understand trauma on a continuum.
Psychological Trauma
physiological arousal PTSD
continuum
10Sunday, 6 February 2011
It’s easier to understand trauma on a continuum.
Psychological Trauma
acute stress disorderphysiological arousal PTS PTSD
addictionsdepressionanxiety
continuum
10Sunday, 6 February 2011
It’s easier to understand trauma on a continuum.
Psychological Trauma
acute stress disorderphysiological arousal PTS PTSD
addictionsdepressionanxiety
continuum
10Sunday, 6 February 2011
It’s easier to understand trauma on a continuum.
PTSD research and statistics
11Sunday, 6 February 2011
PTSD research and statistics
• Scientific method
11Sunday, 6 February 2011
PTSD research and statistics
• Scientific method
• NICE guidelines (UK context)
11Sunday, 6 February 2011
© W Andrews (Feb. 2009)
12Sunday, 6 February 2011
© W Andrews (Feb. 2009)
12Sunday, 6 February 2011
PTSD research and statistics
13Sunday, 6 February 2011
PTSD research and statistics
• Evidence hierarchy
13Sunday, 6 February 2011
PTSD research and statistics
• Evidence hierarchy
• RCT
13Sunday, 6 February 2011
PTSD research and statistics
• Evidence hierarchy
• RCT
• Meta-analysis of RCT studies
13Sunday, 6 February 2011
Meta-Analysis of Risk Factors for PTSD in Trauma-Exposed Adults
14Sunday, 6 February 2011
Meta-Analysis of Risk Factors for PTSD in Trauma-Exposed Adults
2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.
14Sunday, 6 February 2011
2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.
15Sunday, 6 February 2011
Lack of social support is the greatest predictor of the risk of developing PTSD.
2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.
15Sunday, 6 February 2011
Lack of social support is the greatest predictor of the risk of developing PTSD.
Predictors of PTSD
16Sunday, 6 February 2011
Predictors of PTSD
• lack of social support
16Sunday, 6 February 2011
Predictors of PTSD
• lack of social support
• post-trauma life stress
16Sunday, 6 February 2011
Predictors of PTSD
• lack of social support
• post-trauma life stress
• trauma severity
16Sunday, 6 February 2011
• PTSD treatmentNICE Guideline recommendations
17Sunday, 6 February 2011
• PTSD treatmentNICE Guideline recommendations
• Trauma- focused CBT
17Sunday, 6 February 2011
• PTSD treatmentNICE Guideline recommendations
• Trauma- focused CBT
• EMDR
17Sunday, 6 February 2011
Trauma Focused Treatment
18Sunday, 6 February 2011
The list.
Trauma Focused Treatment
• Prolonged exposure
• Image habituation training
• Imaginal flooding (implosive flooding) therapy
• Imaginal exposure and biofeedback-assisted desenitization treatment
• Cognitive reprocessing therapy
• Cognitive restructuring plus exposure
• Cognitive trauma therapy
• Brief eclectic therapy (elements of psychodynamic therapy)
18Sunday, 6 February 2011
The list.
Meta-analysis of PTSD treatments
19Sunday, 6 February 2011
Meta-analysis of PTSD treatments
• Australian Centre for Post-Traumatic Mental Health, 2007
• Bisson & Andrew, 2009
• Bisson et al, 2007
• Bradley et al, 2005
• Seidler & Wagner, 2006
19Sunday, 6 February 2011
Meta-analysis of PTSD treatments
20Sunday, 6 February 2011
Agreement of no difference between trauma focused treatments.
Meta-analysis of PTSD treatments
• Common focus on the patient’s traumatic memories of the traumatic event & personal meaning of the trauma
20Sunday, 6 February 2011
Agreement of no difference between trauma focused treatments.
Meta-analysis of PTSD treatments
• Common focus on the patient’s traumatic memories of the traumatic event & personal meaning of the trauma
• NO DIFFERENCE between ANY of these trauma-focused treatments
20Sunday, 6 February 2011
Agreement of no difference between trauma focused treatments.
Meta-analysis of PTSD treatments
21Sunday, 6 February 2011
Controversy over finding that in fact there is no difference between ANY studied treatments that are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding has been robustly defended.
Meta-analysis of PTSD treatments
• Benish et al, 2008
21Sunday, 6 February 2011
Controversy over finding that in fact there is no difference between ANY studied treatments that are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding has been robustly defended.
Meta-analysis of PTSD treatments
• Benish et al, 2008
• NO DIFFERENCE in OUTCOMES between ANY bona fide treatments, WHETHER TRAUMA FOCUSED OR NOT
21Sunday, 6 February 2011
Controversy over finding that in fact there is no difference between ANY studied treatments that are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding has been robustly defended.
Bill Andrews 2010c
TM
22Sunday, 6 February 2011
Let’s be pragmatic.
Practice Research Networks
23Sunday, 6 February 2011
Practice Research Networks
www.hgiprn.org
23Sunday, 6 February 2011
Pragmatic Research Network
Bill Andrews 2010c
TM
pragmaticresearchnetwork.blogspot.com
24Sunday, 6 February 2011
The main purpose of a network is to try to investigate what is going on in practice.
Ask the Customers (n = 130)
25Sunday, 6 February 2011
The data speaks for itself.
Ask the Customers (n = 130)
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25Sunday, 6 February 2011
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25Sunday, 6 February 2011
The data speaks for itself.
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25Sunday, 6 February 2011
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25Sunday, 6 February 2011
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25Sunday, 6 February 2011
The data speaks for itself.
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26Sunday, 6 February 2011
The effect sizes are large.
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26Sunday, 6 February 2011
The effect sizes are large.
Ask the very distressed (n = 44)
27Sunday, 6 February 2011
Clients seem to be moving to below the cut-off, even when the more distressed cohort are looked at.
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27Sunday, 6 February 2011
Clients seem to be moving to below the cut-off, even when the more distressed cohort are looked at.
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27Sunday, 6 February 2011
Clients seem to be moving to below the cut-off, even when the more distressed cohort are looked at.
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27Sunday, 6 February 2011
Clients seem to be moving to below the cut-off, even when the more distressed cohort are looked at.
Ask the very distressed
28Sunday, 6 February 2011
The data compares very favourably with one of the studies into PTSD from Northern Ireland.
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Duffy et al n = 47bdi conversion
28Sunday, 6 February 2011
The data compares very favourably with one of the studies into PTSD from Northern Ireland.
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Duffy et al n = 47bdi conversion
Andrews et al n = 44CORE-34
28Sunday, 6 February 2011
The data compares very favourably with one of the studies into PTSD from Northern Ireland.
Ask the very distressed
!" #" $!" $#" %!" %#" &!"
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Duffy et al n = 47bdi conversion
Andrews et al n = 44CORE-34
28Sunday, 6 February 2011
The data compares very favourably with one of the studies into PTSD from Northern Ireland.
Predictors of PTSD
• lack of social support
• post-trauma life stress
• trauma severity
29Sunday, 6 February 2011
Likely Predictors of PTSD Resolution
30Sunday, 6 February 2011
Likely Predictors of PTSD Resolution
• recognising the importance of social support
30Sunday, 6 February 2011
Likely Predictors of PTSD Resolution
• recognising the importance of social support
• teaching skills for management of post-trauma life stress
30Sunday, 6 February 2011
Likely Predictors of PTSD Resolution
• recognising the importance of social support
• teaching skills for management of post-trauma life stress
• Using effective techniques to help de-traumatize trauma
30Sunday, 6 February 2011
Likely Predictors of PTSD Resolution
• recognising the importance of social support
• teaching skills for management of post-trauma life stress
• Using effective techniques to help de-traumatize trauma
• Be guided by feedback from service users as to what seems to work in treatment
30Sunday, 6 February 2011
Meta-analysis of PTSD treatments
31Sunday, 6 February 2011
Meta-analysis of PTSD treatments
• NO DIFFERENCE between ANY of these trauma-focused treatments
31Sunday, 6 February 2011
Meta-analysis of PTSD treatments
• NO DIFFERENCE between ANY of these trauma-focused treatments
• (Controversially) NO DIFFERENCE between ANY bona fide treatments, WHETHER TRAUMA FOCUSED OR NOT
31Sunday, 6 February 2011
Where Scientists Agree
32Sunday, 6 February 2011
Possible Factors important to successful treatments of PTSD
Where Scientists Agree
32Sunday, 6 February 2011
• Therapists...ask yourself how many of these you can tick off
Possible Factors important to successful treatments of PTSD
Where Scientists Agree
32Sunday, 6 February 2011
• Therapists...ask yourself how many of these you can tick off
• Service Users...ask yourself how many of these have been honoured in your treatment
Possible Factors important to successful treatments of PTSD
Where Scientists Agree
32Sunday, 6 February 2011
Possible Factors important to successful treatments of PTSD
33Sunday, 6 February 2011
• Cogent rationale that is acceptable to patient
Possible Factors important to successful treatments of PTSD
33Sunday, 6 February 2011
• Cogent rationale that is acceptable to patient
• Set of treatment actions consistent with the rationale
Possible Factors important to successful treatments of PTSD
33Sunday, 6 February 2011
• Cogent rationale that is acceptable to patient
• Set of treatment actions consistent with the rationale
• Development and monitoring of a safe, respectful, and trusting therapeutic relationship
Possible Factors important to successful treatments of PTSD
33Sunday, 6 February 2011
• Cogent rationale that is acceptable to patient
• Set of treatment actions consistent with the rationale
• Development and monitoring of a safe, respectful, and trusting therapeutic relationship
• Agreement about tasks and goals of therapy
Possible Factors important to successful treatments of PTSD
33Sunday, 6 February 2011
• Cogent rationale that is acceptable to patient
• Set of treatment actions consistent with the rationale
• Development and monitoring of a safe, respectful, and trusting therapeutic relationship
• Agreement about tasks and goals of therapy
• Nurturing hope
Possible Factors important to successful treatments of PTSD
33Sunday, 6 February 2011
• Cogent rationale that is acceptable to patient
• Set of treatment actions consistent with the rationale
• Development and monitoring of a safe, respectful, and trusting therapeutic relationship
• Agreement about tasks and goals of therapy
• Nurturing hope
• Identifying patient resources, strengths, survival skills and intra and interpersonal resources in building resilience
Possible Factors important to successful treatments of PTSD
33Sunday, 6 February 2011
Possible Factors important to successful treatments of PTSD
34Sunday, 6 February 2011
• Education about PTSD
Possible Factors important to successful treatments of PTSD
34Sunday, 6 February 2011
• Education about PTSD
• Opportunity to talk about trauma if desired
Possible Factors important to successful treatments of PTSD
34Sunday, 6 February 2011
• Education about PTSD
• Opportunity to talk about trauma if desired
• Ensuring the patient's safety, especially if the patient has been vicitimized (domestic violence, neighborhood violence, or abuse)
Possible Factors important to successful treatments of PTSD
34Sunday, 6 February 2011
• Education about PTSD
• Opportunity to talk about trauma if desired
• Ensuring the patient's safety, especially if the patient has been vicitimized (domestic violence, neighborhood violence, or abuse)
• Helping patients learn how to avoid re-victimization
Possible Factors important to successful treatments of PTSD
34Sunday, 6 February 2011
• Education about PTSD
• Opportunity to talk about trauma if desired
• Ensuring the patient's safety, especially if the patient has been vicitimized (domestic violence, neighborhood violence, or abuse)
• Helping patients learn how to avoid re-victimization
• Fostering independence and self efficacy
Possible Factors important to successful treatments of PTSD
34Sunday, 6 February 2011
Pragmatic Approach
35Sunday, 6 February 2011
The Pragmatic Approach tries to find a middle ground between the different sides of the argument.
Pragmatic Approach
• “Coming down from the lofty perch of ideological purity, pragmatism meets the world as we find it and asks: How can we improve it - not in some ideal way with a predetermined endpoint, but in a practical way in the here and now, within a context of the social, cultural, political, and economic realities we are given?”
1999. Fishman, D.B. The Case for Pragmatic Psychology. New York University Press. New York
35Sunday, 6 February 2011
The Pragmatic Approach tries to find a middle ground between the different sides of the argument.
Pragmatic Research Implications for Innovative Psychological Trauma Treatments
36Sunday, 6 February 2011
• Put the feedback of the service user at the top of the agenda
Pragmatic Research Implications for Innovative Psychological Trauma Treatments
36Sunday, 6 February 2011
• Put the feedback of the service user at the top of the agenda
• Gather robust pre/post data using internationally recognised self-report measures
Pragmatic Research Implications for Innovative Psychological Trauma Treatments
36Sunday, 6 February 2011
• Put the feedback of the service user at the top of the agenda
• Gather robust pre/post data using internationally recognised self-report measures
• Benchmark the results with published data
Pragmatic Research Implications for Innovative Psychological Trauma Treatments
36Sunday, 6 February 2011
• Put the feedback of the service user at the top of the agenda
• Gather robust pre/post data using internationally recognised self-report measures
• Benchmark the results with published data
• Map the innovative treatment onto existing approved treatments
Pragmatic Research Implications for Innovative Psychological Trauma Treatments
36Sunday, 6 February 2011
• Put the feedback of the service user at the top of the agenda
• Gather robust pre/post data using internationally recognised self-report measures
• Benchmark the results with published data
• Map the innovative treatment onto existing approved treatments
• Carry out case study research to elaborate on the features of particular treatments from multiples of perspectives
Pragmatic Research Implications for Innovative Psychological Trauma Treatments
36Sunday, 6 February 2011
• Put the feedback of the service user at the top of the agenda
• Gather robust pre/post data using internationally recognised self-report measures
• Benchmark the results with published data
• Map the innovative treatment onto existing approved treatments
• Carry out case study research to elaborate on the features of particular treatments from multiples of perspectives
• Where funding allows, carry out an RCT to establish the differential effectiveness of the innovative treatment over and above wait-list control
Pragmatic Research Implications for Innovative Psychological Trauma Treatments
36Sunday, 6 February 2011
Steve Hollon
“ with respect to randomization I would paraphrase Churchill on democracy, that it is a terrible process that has little to recommend it except that it is better
than the alternatives”
(Hollon, S. 2009)
37Sunday, 6 February 2011
Paul Salkovskis
Salkovskis, (2002). Empirically grounded clinical interventions: Cognitive-behavioural therapy progresses through a multi-dimensional approach to clinical science. Behavioural and Cognitive Psychotherapy, 2002, 30, 3–9, Cambridge University Press.
38Sunday, 6 February 2011
Paul suggests we need to move away from this evidence hierarchy.
Paul Salkovskis“The risk inherent in the current practice of evidence-based mental health is that the field will degenerate into a parody, a kind of one-dimensional science, and there are signs that this has already occurred to some degree”
Salkovskis, (2002). Empirically grounded clinical interventions: Cognitive-behavioural therapy progresses through a multi-dimensional approach to clinical science. Behavioural and Cognitive Psychotherapy, 2002, 30, 3–9, Cambridge University Press.
39Sunday, 6 February 2011
Prof. Gordon Turnbull
Frontiers in Trauma Treatment
BILL: What in your opinion are the significant breakthroughs in Trauma Treatment?
40Sunday, 6 February 2011
The New Frontier
41Sunday, 6 February 2011
The New Frontier
• unprocessed trauma memories control and cause exaggerated function of the ANS
41Sunday, 6 February 2011
The New Frontier
• unprocessed trauma memories control and cause exaggerated function of the ANS
• PTSD is truly a MIND/BODY experience
41Sunday, 6 February 2011
The New Frontier
• unprocessed trauma memories control and cause exaggerated function of the ANS
• PTSD is truly a MIND/BODY experience
• Emphasis shift to the body focussed therapies
41Sunday, 6 February 2011
The New Frontier
• unprocessed trauma memories control and cause exaggerated function of the ANS
• PTSD is truly a MIND/BODY experience
• Emphasis shift to the body focussed therapies
• Sensorimotor therapy
41Sunday, 6 February 2011
The New Frontier
• unprocessed trauma memories control and cause exaggerated function of the ANS
• PTSD is truly a MIND/BODY experience
• Emphasis shift to the body focussed therapies
• Sensorimotor therapy
• EFT
41Sunday, 6 February 2011
The New Frontier
• unprocessed trauma memories control and cause exaggerated function of the ANS
• PTSD is truly a MIND/BODY experience
• Emphasis shift to the body focussed therapies
• Sensorimotor therapy
• EFT
• Acupuncture
41Sunday, 6 February 2011
The New Frontier
• unprocessed trauma memories control and cause exaggerated function of the ANS
• PTSD is truly a MIND/BODY experience
• Emphasis shift to the body focussed therapies
• Sensorimotor therapy
• EFT
• Acupuncture
• Acupressure
41Sunday, 6 February 2011
The New Frontier
42Sunday, 6 February 2011
The New Frontier
• Soothing the chaos in the right hemisphere
• EMDR
•Mindfulness
42Sunday, 6 February 2011
The New Frontier
43Sunday, 6 February 2011
The New Frontier
•Using a treatment that works on soothing the ANS and works on the right hemisphere is likely to be a good idea
43Sunday, 6 February 2011
Medications
44Sunday, 6 February 2011
Medications
• Propranolol (lowering adrenaline) useful in the Acute Stress Reaction phase to reduce the ‘etching’ of the emotionally charged memories
44Sunday, 6 February 2011
Medications
• Propranolol (lowering adrenaline) useful in the Acute Stress Reaction phase to reduce the ‘etching’ of the emotionally charged memories
• Opiate antagonists (e.g. Naloxone) help to prevent dissociation, which is associated with endorphin flooding
44Sunday, 6 February 2011
Avoidance
45Sunday, 6 February 2011
Avoidance
• Avoidance is a key feature of PTSD and dissociation commonly occurs at the time of the trauma and so becomes an integral part of the flashback
45Sunday, 6 February 2011
Avoidance
• Avoidance is a key feature of PTSD and dissociation commonly occurs at the time of the trauma and so becomes an integral part of the flashback
• Dissociation is probably THE most common cause of treatment resistance
45Sunday, 6 February 2011
Avoidance
• Avoidance is a key feature of PTSD and dissociation commonly occurs at the time of the trauma and so becomes an integral part of the flashback
• Dissociation is probably THE most common cause of treatment resistance
• Even just going to see a Trauma Therapist is enough to make the endorphins ‘pop’
45Sunday, 6 February 2011
Bill’s take home message
46Sunday, 6 February 2011
Bill’s take home message
• have a healthy sense of curiosity
46Sunday, 6 February 2011
Bill’s take home message
• have a healthy sense of curiosity
• keep an open mind
46Sunday, 6 February 2011
Bill’s take home message
• have a healthy sense of curiosity
• keep an open mind
• systematically reflect on your work
46Sunday, 6 February 2011
Bill’s take home message
• have a healthy sense of curiosity
• keep an open mind
• systematically reflect on your work
• take a balanced and informed view of the research
46Sunday, 6 February 2011
Bill’s take home message
47Sunday, 6 February 2011
Bill’s take home message
47Sunday, 6 February 2011
Bill’s take home message
• measure your outcomes
47Sunday, 6 February 2011
Bill’s take home message
• measure your outcomes
• support research and/or get involved in case study research yourself
47Sunday, 6 February 2011
Bill’s take home message
• measure your outcomes
• support research and/or get involved in case study research yourself
• be respectful of other modalities
47Sunday, 6 February 2011
Bill’s take home message
• measure your outcomes
• support research and/or get involved in case study research yourself
• be respectful of other modalities
• trust your clients
47Sunday, 6 February 2011
Pragmatic Research Network
pragmaticresearchnetwork.blogspot.com
48Sunday, 6 February 2011
THE ENDwww.centerforclinicalexcellence.com
49Sunday, 6 February 2011