Beruflich Dokumente
Kultur Dokumente
Education Conferences:
Bangkok, Orlando, Dakar
Empirically-Supported Models of
PTSD Etiology and Treatment
Priscilla M. Schulz, LCSW-C
Peace Corps Headquarters
Counseling and Outreach Unit
Washington, DC
Session Overview
Research-based models
for understanding and treating PTSD
Empirically supported models of post trauma
reactions
o Common psychological responses post trauma
o Normal versus pathological reactions
Empirically supported recommendations for
early post-trauma care
Empirically supported treatments for PTSD
Brief look at Cognitive Processing Therapy
(CPT), a cognitive approach to treating PTSD
DSM-5:
Acute Stress Disorder &
Post-Trauamtic Stress Disorder
A: Stressor Criterion
B: Re-experiencing
C: Avoidance
D: Arousal
E: Negative alterations in cognitions and mood
F: Time Criterion
G: Functional Impairment or Distress
DSM-5 PTSD Symptom Criteria
Re-experiencing Avoidance
1 symptom 1 symptom
Intrusive memories Avoids internal & external reminders:
Nightmares thoughts, feelings, physical sensations;
Psychological and/or physiological people, places, objects, conversations,
distress with reminders situations, & activities
Dissociative reactions Negative changes in
thoughts and mood
Arousal 3 symptoms
3 symptoms Feeling detached/estranged
Hyper-vigilance Disturbed sleep Persistent distorted blame re: trauma
Exaggerated startle Cannot feel positive emotions
Reckless, self-destructive behavior Persistent/exaggerated negative expectations
Irritability, aggression Cannot recall important trauma details
Difficulty concentrating Pervasive negative emotions
Diminished interest/participation
in significant activities
American Psychiatric Assoc May 2013
The Recovery Model of PTSD
Most individuals will have PTSD symptoms after trauma
exposure
Post-trauma psychopathology is not the presence of
clinically significant distress or functional impairment in
the immediate aftermath of trauma exposure.
Post-trauma psychopathology (PTSD) is the lingering of
clinically significant distress and impairment long after
the trauma and life threat is ended.
it may be best to think about diagnosable PTSD
as a disruption of a normal recovery process.
Resick, Monson, & Chard, CPT for PTSD, 2010, p. 3
80
16.0%; N = 19 High chronic
70
60
Moderate
50 6.7%; N = 8 chronic
40 Moderate
47.9%; N = 57 recovery
30 Marked
20 29.4%; N = 35 recovery
10
0
Natural recovery: ~77%
Month 1 Month 2 Month 3 Month 4 Stalled recovery: ~23%
PTSD
Non-PTSD
25
Percentage meeting PTSD
Symptom Criteria
20
15
10
0
1 2 3 4 5 6 7 8 9 10 11 12
Intrusions
Arousal
Negative Irritability
changes in
thought & mood
Intrusions
Arousal
Irritability
Negative
changes in
thought & mood
Intrusions Arousal,
irritability
Negative changes
in thoughts/mood
Intrusions
Arousal,
Negative irritability
changes in
thought & mood
Intrusions
Arousal,
Negative irritability
changes in
thought & mood
CT,
CPT-C
EMDR Escape/Avoidance
CPT
Core PTS Symptom Clusters
PTSD basic points
Immediate, intense reactions to traumatic
experiences are expected and normal
Most survivors recover within about 3 months
Severity of reactions post-trauma is associated
with stalled recovery
Avoidance hinders recovery: Avoidance of
memories, reminders, thoughts and feelings
impede post-trauma recovery
Clinical implications in the 1st hours and days
post-trauma. Providers should address
Safety
Physical injuries
Need for emotional support, companionship
Psycho-education about post-trauma reactions and
recovery
o Normalize PTS symptoms
o Educate about the recovery process
o Encourage active processing
o Discourage avoidant coping
o Identify persons in the survivors environment in whom
he/she can confide and begin the recovery process
EMPIRICALLY MODELS of the
ETIOLOGY OF PTSD
Neurobiological, cognitive, and learning
theory models of PTSD
PTSD is a disorder in which stress-hormone dys-
regulation, and corresponding brain dys-function,
undermines emotion regulation and thinking. Research
suggests this occurs at the time of the trauma, and with
memories long after the trauma occurred.
Bremner et al, 1999b; Milad et al., 2009; Morgan et al, 2000; 2001,
2004; 2006; Rauch et al., 1998, 2000; Shin et al., 2001
Pre Frontal Cortex:
Executive functioning
Amygdala:
Initiates increased vigilance
& defensive preparations in
response too uncertain or
novel stimuli that may be a
threat
Hippocampus:
Weighs relevance of parts
or experience; perceives
context; inhibits fear
conditioning
HPA Axis:
Hypothalamus
Pituitary, and Adrenal Cortex
The Fight-Flight response
Normal Human
Response to Threat Cerebral Cortex
involves a cascade of
DA
central and peripheral
(-) Hippocampus 5HT
nervous system events.
Survival is primary. ((-) NE
(-) Amygdala
Midbrain &
manifests as fight or Brainstem
Glutamate++
flight SNS
Hypothalamus
Glucocorticoids:
CRF
Cortisol
Threat Pituitary
Allopregnanalone
DHEA
Neuropeptide Y
ACTH
Adrenal Cortex
An optimal zone defensive response involves key
neurotransmitters alternating between excitation
and down-regulating the response
Norepinephrine
Fear; flight; learning &
remembering about danger
Serotonin GABA
(5HT) Calming; modulates stress
hormone levels; supports
Rage; fight; self- good cognitive functioning;
defense; aggressive decreases CRF (decreasing
retaliation; attenuation HPA response & NE
of fear release)
How the Amygdala sees threat
Conceptualization courtesy of Ann Rasmusson, MD, Yale University & Boston VA Healthcare System
Top-Down Governance
Hippocampus
context
(-) probability
Glucocorticoids:
Threat CRF
Cortisol
Pituitary
Allopregnanalone
DHEA
Neuropeptide Y
ACTH
Adrenal Cortex
PTSD vulnerability: Physiological
responses outside optimal levels undermine Cerebral Cortex
emotion regulation & memory formation
DA
Peri-trauma, this
5HT
manifests as dissociative
(-) (-)
reactions. Hippocampus
NE
(-)
Amygdala BDNF Midbrain &
Post-trauma, this (-) Brainstem
Glutamate
manifests as memory
GABA Glucocorticoids:
inaccuracy & problem- Hypothalamus
Cortisol
solving deficits. Allopregnanalone
CRF DHEA
Threat Pituitary Neuropeptide Y
Peri-traumatic dissociation Milad et al. (2009);
increases risk of emotional
Rauch et al. (2006);
overwhelm, increasing risk ACTH
of immediate onset PTSD Southwick et al.
(Ozer et al., 2003) (2005); Shin et al.
Adrenal Cortex
(2005)
Research with US Special Forces found stress hormone dys-
regulation undermined Soldiers and Marines ability to
respond to threat in high stress/live-ammo training
exercises. This resulted in performance deficits including
confusion relaying map coordinates, difficulty operating
weapons, and psychological collapse under mock
interrogations.
Birmes et al., 2003; Dunmore et al., 2001; Halligan, Michael, Clark, & Ehlers (2003)
1. LACKING SELF-REFERENCE
persons dont recognize themselves during the trauma
2. DISSOCIATIVE PROCESSING:
perspective, sense of time & space are distorted
3. DATA-DRIVEN,SENORY FOCUSED:
persons are overwhelmed by sensory experiences
At the mercy of an emotional mind, survivors with PTSD share
Common Interpretative Biases
The world is unpredictably dangerous
People are untrustworthy
No place is safe
Threats could appear at any moment
Its my fault (Im bad)
My training tells me outcome reflects preparations. The outcome was bad;
the mission my responsibility. So the only conclusion left is: its my fault
I promised Id bring everyone back alive
I should have/could have done something
I believe good things happen to good people
I am unable to cope (Im incompetent)
PTSD symptoms are a sign of weakness
Other people would get over it
Associative LTP
Unconditioned
Stimulus Conditioned
Stimulus
Post-trauma Fear Structure
Representation of The meaning associated
Physiological
feared, trauma-related with stimuli &
fear response
stimuli responses
People walking Racing heart Someones coming to hurt
behind you Sweating me!
Pictures of bears or Agitation I cant protect myself.
Alaskan wilderness Panic Im in danger!
The smell of mens Escape No place is safe!
aftershave behaviors
Craske et al., BRT, 2008; Foa et al., 2007, PE for PTSD; Foa & Kozak, Psychological
Bulletin,1986; Foa et al., 2006; Foa & Rothbaum, 1998; Lang, 1979; Lang et al., 1998
Operant conditioning maintains the link between
trauma reminders and a sense of dangerousness
Trauma memories
cause distress
Distract self,
Avoid anything
prevent
that triggers
opportunities to
memories
remember
Trauma memories
intrude and cause
distress
Conditioned fear remains intact until new associations
rival the ones learned during the trauma
Amygdala
New learning prevents
activation of threat
response
Craske, M. G. (2010); Craske, M. G., et al. (2008); Myers & Davis (2007
Clinical implications based on PTSD models:
1st weeks post-trauma
1. Assessment:
a. Primary Care PTSD Screen (PC-PTSD)
b. Descriptions of symptom change since the incident:
Im not as upset as I was the first week versus
If the nightmares dont stop Im going to go crazy!
c. Survivors behavior coping with the trauma:
Avoiding people? avoiding eye contact?
increased use of benzos or alcohol? versus
Calling home. Talking with OVA, COU. Accepting
companionship. Seems calmer/ more focused daily
Primary Care PTSD Screen
Have had nightmares about it or thought about it when you did
not want to? YES / NO
Tried hard not to think about it or went out of your way to avoid
situations that reminded you of it? YES / NO
Genetic variants:
Kinds of trauma & FKBP5
age of exposure SLC6A4
PTSD & RGS2
related
phenoptypes:
PTSD
Good post-
trauma
recovery
FKBP5 rs 1360780 GG
Epigentics and PTSD:
Early trauma may alter the function of a gene involved in
the human stress response resulting in problematic stress
responses when exposed to later traumatic events.
CHLDHOOD TRAUMA
POST-TRAUMA RESPONSE
Severity, FKBP5 PTSD+
frequency NR3C1 No PTSD
childhood
abuse SLC6A4 etc Subsyndromal
PTSD
1. Gene-Environment Interaction (GxE): The effects of adult trauma
exposure are moderated by genotype, AND by levels of childhood abuse that
appears to affect gene expression through epigentic changes.
90%
80%
70%
No sexual or physical
lifetime PTSD (CAPS)
60% abuse
Percentage with
Peri-traumatic dissociation
Perceived life threat
Prior emotional problems
Family of origin psychopathology
Prior trauma
Perceived [lack of] support post-trauma
Low IQ
Difficult temperament, antisocial behaviors,
unpopular among peers
Low family SES
Multiple changes in residence before age 11
Changes in a parent figure (e.g., divorce,
death, etc.)
Mothers identified with internalizing personality
traits
Koenen, Moffitt, Poulton, Martin & Caspi (2007).
Clinical implications of risk & resilience
information about PTSD:
1. Consider the Volunteers mental health history:
a. Volunteers with prior psychiatric difficulties may experience
similar problems after a traumatic event
2. Screen for PTS reactions: Severity may suggest risk
3. Assess for PTSD at 1-month post trauma
4. Follow-up with Volunteers with childhood adversity histories
who may hide or minimize current distress
5. Help Volunteers use skills learned from other difficulties to
address emotional difficulties in the aftermath of a trauma:
a. How did the Volunteer calm & support herself after PST?
b. How did she garner support when feeling lonely or scared?
RESEARCH-SUPPORTED
TREATMENTS of PTSD
Values Hopes
Expectations
Biases
State-of-mind
Motivation
Meaning stems from an interaction
Trauma
Im in I could have
control of prevented this
my life
Think happy
thoughts
Beliefs
Trauma
I mustve done
something
and wrong
Trauma
Beliefs
The world is safe
The world is
Powerlessness completely unsafe
CPT identifies beliefsprior beliefs, trauma
conclusions, and how these ideas affect wellbeing
Trauma Danger
RECOVERY
Pre Post
90
80
70
CAPS SEVERITY
60
50
40
30
20
10
0
Resick et al. Chard (2005) Monson et al. Resick et al. Forbes et al. Suris et al.
(2002) (2006) (2008; CPT) (in press) (under review)
BDI SEVERITY PRE- AND POST-TREATMENT
(INTENT-TO-TREAT)
Pre
30
Post
25
20
BDI Severity
15
10
5
0
Resick et al Chard Monson et al Resick et al Forbes et al
(2002) (2005) (2006) (2008) (in press)
CPT
RANDOM REGRESSION
OF PDS
82
Long-term impact of CPT and PE:
PTSD symptom improvement is maintained over time.
PTSD Symptom Severity (CAPS)
2.5
CPT
PE
2
1.5
0.5
0
PreTx PostTx 3 MO 9 MO 5+ Yrs
Resick et al.,2002; 2011
86
The end.
Thank you!