Ptsd resolution5.2

PTSD research and statistics

Bill Andrews

Pragmatic Research Network

Sunday, 6 February 2011 1

PTSD treatment: the facts;
outcomes of therapy

Bill Andrews



Bill Andrews
Research Coordinator



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 Andrews
Senior advisor
ICCE
www.centerforclinicalexcellence.com


The ICCE is a great resource.

What is PTSD? 1/6

DSM-IV-TR, APA, 2000


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



What is PTSD? 2/6



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



What is PTSD? 3/6



What is PTSD? 3/6

• C: Persistent avoidance of stimuli
associated with the event(s)



What is PTSD? 4/6



What is PTSD? 4/6

• D: Elevated arousal that was NOT present
prior to the event(s)



What is PTSD? 5/6



What is PTSD? 5/6

• E: The symptoms must persist for more
than 1 month



What is PTSD? 6/6



What is PTSD? 6/6

• F: The disturbance causes clinically
signiﬁcant distress or impairment in social,
occupational, or other important areas of
functioning



Psychological Trauma


It’s easier to understand trauma on a continuum.

continuum



continuum
physiological arousal



continuum
physiological arousal PTSD



continuum
physiological arousal acute stress disorder PTS PTSD

anxiety depression addictions




• Scientiﬁc method



• Scientiﬁc method
• NICE guidelines (UK context)



• Evidence hierarchy



• RCT



• RCT
• Meta-analysis of RCT studies


Meta-Analysis of Risk Factors for
PTSD in Trauma-Exposed Adults


Meta-Analysis of Risk Factors for
PTSD in Trauma-Exposed Adults

2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.


2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.

Lack of social support is the greatest predictor of the risk of developing PTSD.

Predictors of PTSD


Predictors of PTSD

• lack of social support


Predictors of PTSD

• post-trauma life stress


Predictors of PTSD

• trauma severity


• PTSD treatment
NICE Guideline recommendations


• PTSD treatment

• Trauma- focused CBT


• PTSD treatment

• Trauma- focused CBT
• EMDR


Trauma Focused Treatment


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)


The list.

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



Agreement of no difference between trauma focused treatments.


• Common focus on the patient’s traumatic
memories of the traumatic event &
personal meaning of the trauma




• 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





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


• Benish et al, 2008




• Benish et al, 2008
• NO DIFFERENCE in OUTCOMES
between ANY bona ﬁde treatments,
WHETHER TRAUMA FOCUSED OR NOT



TM

c Bill Andrews 2010


Let’s be pragmatic.

Practice Research Networks


Practice Research Networks

www.hgiprn.org


TM

c Bill Andrews 2010

pragmaticresearchnetwork.blogspot.com


The main purpose of a network is to try to investigate what is going on in practice.

Ask the Customers (n = 130)


The data speaks for itself.

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The effect sizes are large.

Ask the very distressed (n = 44)


Clients seem to be moving to below the cut-off, even when the more distressed cohort are
looked at.


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looked at.


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Ask the very distressed


The data compares very favourably with one of the studies into PTSD from Northern Ireland.


Duffy et al n = 47
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Duffy et al n = 47 Andrews et al n = 44
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Predictors of PTSD

• trauma severity


Likely Predictors of
PTSD Resolution


PTSD Resolution
• recognising the importance of social support


PTSD Resolution

• teaching skills for management of post-trauma
life stress


PTSD Resolution

life stress

• Using effective techniques to help de-
traumatize trauma


PTSD Resolution

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



• (Controversially) NO DIFFERENCE
between ANY bona ﬁde treatments,
WHETHER TRAUMA FOCUSED OR NOT


Where Scientists Agree



Possible Factors important to successful treatments of PTSD




• Therapists...ask yourself how many of these you can
tick off




• 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


• 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






• Nurturing hope

• Identifying patient resources, strengths, survival skills and
intra and interpersonal resources in building resilience



• 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)





violence, or abuse)

• Helping patients learn how to avoid re-victimization





violence, or abuse)

• Helping patients learn how to avoid re-victimization

• Fostering independence and self efﬁcacy


Pragmatic Approach


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

The Pragmatic Approach tries to ﬁnd a middle ground between the different sides of the
argument.

Pragmatic Research Implications for
Innovative Psychological Trauma Treatments



• Put the feedback of the service user at the top of the agenda




• Gather robust pre/post data using internationally recognised self-report
measures




measures

• Benchmark the results with published data




measures


• Map the innovative treatment onto existing approved treatments




measures



• Carry out case study research to elaborate on the features of particular
treatments from multiples of perspectives




measures



• 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


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)


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.


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.


Prof. Gordon Turnbull
Frontiers in Trauma Treatment

BILL: What in your opinion are the
significant breakthroughs in
Trauma Treatment?


The New Frontier


The New Frontier

• unprocessed trauma memories control and cause
exaggerated function of the ANS


The New Frontier


• PTSD is truly a MIND/BODY experience


The New Frontier



• Emphasis shift to the body focussed therapies


The New Frontier




• Sensorimotor therapy


The New Frontier





• EFT


The New Frontier





• EFT

• Acupuncture


The New Frontier





• EFT

• Acupuncture

• Acupressure


The New Frontier


The New Frontier

• Soothing the chaos in the
right hemisphere
• EMDR
• Mindfulness


The New Frontier


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


Medications


Medications

• Propranolol (lowering adrenaline)
useful in the Acute Stress Reaction
phase to reduce the ‘etching’ of the
emotionally charged memories


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


Avoidance


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


Avoidance


• Dissociation is probably THE most
common cause of treatment resistance


Avoidance


• 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’


Bill’s take home message



• have a healthy sense of curiosity



• keep an open mind



• systematically reﬂect on your work



• systematically reﬂect on your work
• take a balanced and informed view
of the research



• measure your outcomes



• support research and/or get involved
in case study research yourself



• be respectful of other modalities



• be respectful of other modalities
• trust your clients


pragmaticresearchnetwork.blogspot.com


THE END
www.centerforclinicalexcellence.com

wandrews22@mac.com


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