Clinical Perspective Block 2 PDF

Clinical perspective block 2 Lecture 1 PTSD prevalence in students = 7.1% Another 8% sub-clinical Majority (about half) recover within 3 months after trauma Post traumatic growth (PTG) - Positive mental shift experienced as result of adversity - 90% people report at least one benefit...

Clinical perspective block 2 Lecture 1 PTSD prevalence in students = 7.1% Another 8% sub-clinical Majority (about half) recover within 3 months after trauma Post traumatic growth (PTG) - Positive mental shift experienced as result of adversity - 90% people report at least one benefit - Areas o Relationships valued more deeply o Self-esteem o Meaning/perspective on life - How o Embrace your natural response o Share in a safe space (constructive self-disclosure) o Find personal strengths Criterion A: trauma exposure Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: - Directly experiencing - Witnessing the event(s) in person as it occurred to others - Learning that the traumatic event(s) occurred to a close family member or close friend o In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental - Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) o First responders, police Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related Life-threatening illness not necessarily traumatic 1 Acute medical events can be However, people with (chronic) illnesses or planned abortion to show some PTSD symptoms Criterion A conclusions - Relationship between severity of event and symptoms - Events are distant causes. True causes lie within person and person-environment interaction o Haystack analogy o Everyday cyclist throws match into haystack o On rainy days no effect o On dry days it does o → is an interaction - Demarcation is arbitrary/practical/political rather that objective/scientific o We don’t do this for causes in other disorders (e.g., depression, phobia) - Ignores emotional abuse/neglect - DSM allows for perpetrators to develop PTSD Critique Medicalize normal stress - Some critique that PTSD diagnosis medicalized normal stress response - However, some people do show chronic (i.e., ‘abnormal’) symptoms in response to traumatic stress (→ PTSD) - PTSD patients do show specific neurobiological characteristics - So PTSD is valid and distinct psychiatric condition A-criterion doesn’t suffice - Demarcation trauma - Reliable reporting/measurement of trauma and (in DSM-IV) accompanying emotions - Relation trauma to PTSD and other disorders - Reliance on criterion leads to diagnostic inconsistencies and unnecessary for defining PTSD Overlap with other disorders - Reexperiencing - Avoidance o Anxiety disorders - Negative thoughts/emotions o Mood disorders 2  - Hyperarousal Proposed changes - Abolish criterion A - Less (and most characteristic/specific) symptoms o A lot of different combinations of PTSD symptoms possible now Intrusions according to Brewin - Reexperiencing – should be present in past month or, exceptionally, on examination. Either: - Recurrent distressing dreams related to an event now perceived as having severely threatened someone’s physical or psychological well-being, from which the person wakes with marked fear or horror, or - Repeated daytime images related to an event now perceived as having severely threatened someone’s physical or psychological well-being, experienced as recurring in the present and accompanied by marked fear or horror Avoidance according to Brewin - Avoidance – should be present in past month. Either: - Efforts to avoid thoughts, feelings, conversations, or internal reminders associated with the reexperienced event(s), or - Efforts to avoid activities, places, people, or external reminders associated with the reexperienced event(s) Arousal according to Brewin - Hyperarousal – should be present most days in past month. Either: - Hypervigilance, or - Exaggerated startle response Advantages of these alterations - Increased diagnostic clarity o Simplified criteria o Remove criterion A → focus on symptoms ipv event - Enhanced specificity o Narrow criteria → reduce overlap - Improved research and treatment 3 Potential disadvantages - Debate over core symptoms - Risk of diagnostic overreach o Remove criterion A → include reactions of any stressor → overdiagnosis Criterion B: intrusion symptoms At least 1 - Recurrent, involuntary, distressing memories - Distressing dreams related to trauma - Dissociative reactions (flashbacks) - Intense distress to cues about trauma Criterion C: avoidance symptoms At least 1 - Avoiding memories, thoughts or feelings about the trauma - Avoiding external reminders Criterion D: negative cognitions and mood At least 2 - Inability to recall key aspects - Persistent negative beliefs about yourself, others or the world - Distorted blame - Persistent negative emotions - Reduced interest in activities - Detachment from others - Inability to experience positive emotions Criterion E: altered arousal and reactivity At least 2 - Irritable behavior and angry outbursts - Reckless or self-destructive behavior - Hypervigilance - Exaggerated startle response - Difficulty concentrating - Sleep disturbances Symptoms must be 1+ month, cause significant distress/impair functioning and are not due to substance use/medical condition 4 PTSD with dissociative symptoms: includes depersonalization and derealization PTSD with delayed expression: full criteria not met until 6+ months after trauma Prevalence - Lifetime risk: 8.7% in US, 1% in Europe, Asia and Africa - Higher in groups with increased trauma exposure - Highest rates among survivors of rape, military combat and genocide Risk and prognostic factors - Pretraumatic o Childhood adversity, prior trauma, low SES, mental health history - Peritraumatic o Trauma severity, perceived life threat, interpersonal violence, dissociation during event - Posttraumatic o Lack social support, repeated reminders of trauma, subsequent life stressors Comorbidity - Third factors can cause PTSD and/or comorbid diagnosis - Acute stress, PTSD and adjustment disorder can’t be comorbid - Adjustment disorder: have experienced trauma, but no full symptom picture - OR no trauma (according to criteria) but have full symptom picture - Complex PTSD o Not in DMS, is in ICD o Additional symptoms ▪ Problems in affect regulation ▪ Negative beliefs about one self ▪ Difficulty in sustaining relationships/closeness - 80% of people with PTSD have comorbid disorders Empirical findings - Participants had mixed civilian trauma - 13% lost PTSD diagnosis o 62% of those had comorbid disorder (MDE, anxiety) - 13% gained diagnosis - Less comorbid depression under ICD-11 than under DSM-IV - Comorbidity is a function of PTSD criteria set 5 80% experience traumatic events in their life 7.4% of general public have (had) PTSD Predictors of PTSD - Prior trauma - Prior adjustment - Family history of psychopathology - Perceived life threat o Intermediate predictive strength - Perceived support o Intermediate predictive strength - Peritraumatic emotions o Intermediate predictive strength - Peritraumatic dissociation o Strongest of these 7 o Might interact with heightened arousal o → shape memory formation and emotional processing Moderator effects - Type of trauma - Time elapsed - Assessment method (interviews over self-report) Strongest: - Trauma severity - Lack of social support - Life stress Conclusions of meta-analysis - Despite heterogeneity/complexity, developing PTSD is not ‘random’ - Effect sizes for several predictors are not trivial - A distinction emerges between distal (past, static) vs proximate (peri- /posttraumatic, dynamic) predictors - Proximate predictors showing larger effect sizes and possibilities for intervention - Nevertheless, most variance unexplained 6 Lecture 2 Cognitive model of Ehlers & Clark (2000) - Most recent ‘big’ PTSD model - Synthesis earlier models - Clear implications for treatment - Model of chronic/persistent PTSD o Not acute stress - PTSD develops and persists when individuals process trauma in ways that generate sense of current threat Trauma related cognitions - About trauma event itself - About consequences o Initial symptoms o Other people’s reactions o ‘irreversible harm’ - Negative appraisal o Extern o Intern - Danger → fear - Violation of rules/norms → anger - Responsibility → guilt - Violation internal norms → shame Nature of trauma memory - More sensory/visual than narrative - Here-and-now quality - Difficult to correct - Affect without recollection - Easily triggered Encoding/storing trauma-related info in memory - Incomplete/imperfect integration in autobiographical memory system o → less intentional recall, more unintentional recall - Strong S-S en S-R associations - Strong sensory priming for S’s Strategies to control threat/symptoms - Can be functional vs dysfunctional 7  - Avoidance - Though suppression - Safety behaviors (reinforce belief that world is unsafe - Substance use - Rumination (e.g. about possible prevention) - Cognitive disengagement Additional influences on PTSD persistence - Cognitive processing during trauma o More focus on sensory impressions (data driven, vs conceptual) more fragmented memories o Mental defeat - Background factors o Prior trauma o Beliefs o Event characteristics Peri-dissociation (during trauma) 3 core elements (in square), which can be worked on in therapy PTSD features explained Delayed onset of PTSD - Later event gives original event new (more threatening) meaning - Trauma reminders only become available after some time 8 Anniversary reactions - Increased external and internal reminders - Negative appraisals Frozen in time - Negative appraisals - Disconnect from reality through continuous reexperiencing - Abandoning/avoiding activities Anticipatory anxiety - Nature of trauma Talking or thinking about trauma doesn’t help - Ruminating - Emotional avoidance Interventions for PTSD Debriefing - Attention for secondary prevention / early intervention - Trauma clear risk factor - Good intentions - Refers to range of interventions - Vary in content, form and target population - Single session, ± 2 hours, several days post trauma - Emergency personnel, then civilians/primary victims - 7 phases: introduction, facts, thoughts, feelings, symptoms, education, closure - Possible aims: prevention, support, education - Effects o Critical incident stress debriefing = CISD o Effect sizes non-significant for CISD, might even hinder natural recovery o Positive effect sizes for non-CISD and control (no intervention) - Possible explanations o Disturbs natural processing/oscillation of reexperiencing vs. avoidance o Discourages using social support o Sensitization instead of habituation/no corrective information - Don’t necessarily need to stop debriefing, but have to be clear about aims - Need to study predictors for whom debriefing is useful 9  - Guidelines are against debriefing Pharmacological treatment - May be effective - Cannot process, but may help to process - Symptoms reduction after pharmacotherapy may lead to: o More avoidance (→ no processing) o Less avoidance (→ processing) - Possibility of side effects and relapse o But also for psychological therapy - Guidelines: only in step 4, not preferred choice o As addition or mono therapy Trauma-focused CBT interventions - Cognitive processing therapy - Trauma-focused CBT - Narrative exposure therapy - Prolonged exposure therapy - EMDR Dutch guideline - Step 1 Diagnosis - Step 2: First choice treatment - Step 3: Try another first choice treatment - Step 4: Intensified care (e.g. meds, condensed) - Step 5: Alternative/complementary treatments Prolonged exposure - In vivo/imaginal - Patient exposes oneself to traumatic memories through internal (imaginal) or external (in vivo) cues, until they no longer evoke problematic fear - Imaginal exposure: first person present tense, ‘as if it is happening again’ - Therapist guided in session, audiotapes (imaginal) or homework (in vivo) between sessions How it works - Learning theory o Neutral stimuli become associated with anxiety response (classical conditioning) o Avoidance of these stimuli becomes reinforced by reduced fear (operant) o Avoidance hinders extinction, fear and avoidance remain 10  o Exposure promotes extinction, fear and avoidance reduce - Cognitive theory o Changes in explicit/verbal cognitions about trauma (and about exposure) o Changes in memory representation (elaboration, integration in autobiographic memory) Cognitive processing therapy (CPT) - Focus on distorted beliefs formed after trauma - Identifying and challenging maladaptive beliefs Trauma-focused CBT - Prolonged exposure (imaginal and in vivo) + cognitive restructuring - Cognitive restructuring = identifying and modifying irrational dysfunctional cognitions Writing therapy - High adaptability o Can be done online or face-to-face, all ages - Include elements of o Imaginal exposure ▪ Write about event in present tense ▪ Reduce emotional reactivity through habituation and extinction o Cognitive restructuring ▪ Advice for a friend in the same situation ▪ Challenge maladaptive beliefs ▪ Promote adaptive coping strategies o Social sharing and closure ▪ Write to someone close, share experiences and what you want from them ▪ Foster social support - Low threshold - Does seem effective, similar to CBT - Can also be used complementary to other treatments EMDR (eye movement desensitization and reprocessing) Working memory theory - Traumatic memory restored into long term memory - Long term memory (stable) - Working memory (liable, limited capacity) - Competing task (follow eye movement) reduces vividness and emotionality traumatic memory 11  - Modified memory reconsolidation into long term memory - Instructed to recall distressing memories during working memory task Theoretical foundations EMDR - Adaptive information processing model o Trauma disrupts ability to integrate and process experiences o Traumatic experience is isolated/disconnected o EMDR → reintegration → reduce emotional charge - Working memory taxation o Engaging WM during trauma recall → reduce vividness and emotional intensity o Compete for cognitive resources Complex PTSD doesn’t need additional treatment Lecture 3 People belonging to WEIRD category generally have better treatment outcomes Knowledge base mainly from WEIRD populations, but is actually a minority Culture … shapes expression of mental health symptoms … influence coping strategies and help-seeking behaviors … determine how individuals experience stigma and recovery Culture is determinant of health and mediating factor for other social determinants Mental health inequity - Due to structural and cultural factors - Psychotherapy works for all groups/populations - Psychotherapy seems less effective among minorities o Smaller effect sizes - Minority patients have higher risk of drop out o Twice as high as native population - Treatments are less intensive among minorities 12  o Less sessions per time unit o Treatment intensity is predictive of outcome Maybe due to more stressful life circumstances, lower SES DSM has goal to develop diagnosis/treatment plan that is informed by individual’s cultural and social context Only a disorder when there is a significant difference from the relevant cultural norm for that individual Our theories & definitions of mental disorders are largely based on western (Euro- American) norms, views, values and concepts Cultural dimensions - Collectivism vs individualism - Independent vs interdependent self-concept - Traditional vs non-traditional gender roles - Emotional expressiveness vs emotional inhibition - Supernatural vs material Higher risk of misdiagnosis when individual relates more to the right side Cultural definition of pathology - Changes - Homosexuality - Frigidity (women no orgasm during penetration) - Drapetomania (obsessive need among slaves to flee) Culture’s impact on distress - Cultural norms and values affect pathogenesis - Cultural beliefs on health and illness emphasize certain symptoms (over the others) o E.g. physical over psychological o Vocabulary - Cultural norms determine the type of symptoms expressed: o Anorexia nervosa o Taijin kyofusho ▪ Fear of appearing rude ▪ Western social anxiety: about social skills, appearing competent 13  - Cultural beliefs determine the boundaries between normal and abnormal phenomena - Language and communication norms affect the expression of symptoms o Verbal, facial - Cultural beliefs determine the experience and explanation of symptoms Cultural concept of distress - Idioms of distress o Culturally constituted experiences and expressions of distress, which are associated with culturally pervasive values, norms and health concerns, and initiate particular types of interaction o In daily life but also clinical contexts o E.g. down, burn out o Study ▪ Collect cultural idioms in Afghanistan after war ▪ Experiences more expressed in cultural idioms than PTSD symptoms - Cultural syndromes - Explanatory models of illness o Causes o Timing o Pathophysiology o Course (nature, severity) o Preference for treatment o Different attributions of symptoms can alter experience Disagreement on psychological explanations ➔ Worse treatment outcome ➔ And more often cancel appointments Need to take into account the patient’s cultural explanations Cultural formulation - Cultural definition of the problem - Cultural perceptions of cause, context, support - Cultural factors affecting self-coping and past help seeking - Cultural factors affecting current help seeking Strategies for culturally responsive mental healthcare - Cultural competence 14  o Understanding cultural backgrounds and how that affects mental health o Limitations ▪ Relies on stereotypes ▪ Frames cultural as something of client, ignoring cultural biases of practitioners o Practitioners have to be self-reflective - Cultural safety o Developed by indigenous communities o Addresses power dynamics, historical oppression and systemic discrimination o Share power between patient and provider - Language interpreters o Professional interpreters improves communication, diagnosis and treatment outcomes - Culture brokers o Professionals mediate between patient and provider - Health workforce diversity - Expanding evidence base Key policy recommendations - Cultural competence and safety training o Mandatory training o Accreditation standards for healthcare institutions - National standards for interpreters o Enforce regular use of prof interpreters o Adequate funding and training - Development of culture brokers - Systemic integration of culture Theoretical developments in culture and psychopathology - Dynamic interaction between individual and culture - Challenge simplistic ethnic or national categorizations - Interplay of neurobiological and social factors in psychopathology Developmental and contextual perspectives - Social determinants in cultural contexts contribute to mental health - Interactional models of genes, environment and culture Cultural influence on specific disorders - Mood disorders o Core symptoms shaped by cultural values o Cultural attitudes toward emotions 15  - Anxiety disorders o Prevalence and expression vary - Somatization and psychologization o Psychological distress often expressed in physical symptoms in non-western cultures - Psychotic disorders o Migrants and minority groups have higher risk due to social adversity Integrations of culture in DSM-5 - Categories for: cultural syndromes, cultural attributions and cultural idioms of stress Research and methodological challenges - Limited cross-cultural validity - Should focus on specific developmental and contextual processes ipv broad categories Emerging trends and directions - Cultural neuroscience - Social determinants of mental health - Digital culture and identity Lecture 4 Guidelines / quality standards - The law prescribes that a professional provides good care in accordance with the professional standard and quality standards (Wkkgz) - There is no single national definition of quality standards. Many different terms are used o Guidelines & quality standard most common Guidelines - Professional recommendations for diagnosis and treatment - Based on scientific research - Explicitly describes what a professional can offer to a patient - Profession specific (depression for psychiatrist, gp, …) - Practice guidelines: professional conduct - Treatment guidelines: effective treatments for certain condition 16 Quality standard - Describes what we mean by good care for certain mental illness or a generic theme - Based on o Scientific knowledge (related guidelines) o Clinical experience (knowledge and experiences professionals) o Experiences and preferences of patients (& family) - A quality standard explicitly describes what a patient can expect from mental health care - Not profession specific, umbrella agreement How are quality standards made - Patients, their relatives and health professionals together in a working group; not influenced by healthcare providers or financers - They collect all information about the subject and try to reach consensus - Put your own interests aside and put those of the patient first Why do we have quality standards - In general: reduce practice variations - For patients and their relatives: clarity about what they can expect & what are the options in care and treatment - For patients and professionals: basis for making choices about care and treatment (shared decision making) - For professionals and mental health care centers: insight into how to organize good care Are quality standards mandatory? - Yes - Dutch law prescribes: professional works according professional standards - But ‘one size fits all’ not always possible or desirable - Principle of ‘comply or explain’. It’s okay if you and the patient make other decisions, as long as you can explain why How to know what to do - Education - Basic (textbook) methods - Mental healthcare standards - Team of professionals - Listen and understand patient’s story - Use common sense 17 Evaluating therapy - Determine goals o Problem, what goal and how to achieve o Sometimes visualization (bar) - Evaluate every step with patient - Agree on how to evaluate o How often o With whom o Use Routine Outcome Monitoring (ROM) questionnaires? ▪ Helps to estimate severity of symptoms ▪ Recognize in time when patients doesn’t recover well enough - What have we achieved, if not as expected: why? - How do you continue Learning and improving - Creating a culture of continuous learning, reflection, and improvement that benefits both patients and health care professionals o Higher quality of care o Better outcomes o More efficient care Benchmarking - In Dutch mental health care - Compare information (data) about the care process, type of patients, treatment outcomes and/or patient experiences with others - Can compare your organization with other organizations Participation in learning network - In a learning network, you share and discuss experiences in order to develop new insights and initiatives for further improvement of the quality of care in practice - Network acute psychiatric care o Network of professionals working in acute psychiatric care o One professional per acute psychiatric region (28 in total in the Netherlands) o Aim: reducing practice variation to increase quality of acute psychiatric care - Discuss change and differences 18 Lecture 5 Loneliness = discrepancy between an individual’s preferred and actual social relations - Different from social isolation and solitude (positive experience of being alone) o Loneliness is subjective experience, isolation/solitude more objective - Distinct from depression Distinctions - Emotional / intimate o Miss intimate social connections - Social / relational o Miss social network around you - Collective o Feel that you don’t belong to broader groups o No shared identity with people around you Related risks - Mental health o Depression, anxiety - Physical health o Cognitive decline, CVD, immunity, mortality, Alzheimer’s progression - Behavioral and social o Impulsive, aggression, hypervigilance to social threats, no interpersonal connections Evolutionary perspective - Survival depends on collective ability/act together as social species - Loneliness as aversive signal - Intended response to loneliness to get connected - Need to belong o Desire for interpersonal attachments is fundamental human motivation - Transient healthy loneliness o Loneliness increases motivation to connect and behave socially o Natural resolution? Loneliness is increasing problem Chronic loneliness Loneliness related to deathly symptoms Self-sustaining 19 Loneliness becomes self-fulfilling prophecy Their behavior also influences behavior of those around you Experiment - Participants fill out personality questionnaire - Then have conversation with other participant - Participants were told their conversation partner would express liking or disliking to them based on their questionnaire responses - This influenced how both participants behaved - Liking: more open, warm and positive Believing that others dislike makes you more vulnerable to rejection and isolation Cognitive biases: systematic thinking errors when processing and interpreting info Influences how we perceive things Interpretation bias - Interpret (social) ambiguity often in negative ways - Often measured with vignette studies - Both social and emotional loneliness predictive of having negative interpretations related to unavailability of social network - Social loneliness predictive of negative interpretation related to rejection 20 Attribution bias - Causes people assign to outcomes/behavior - People who score high on loneliness more often attribute social failure to enduring, unchangeable deficits in yourself - Positive social events attributed to unstable, external factors - Negative social events attributed to stable, internal, uncontrollable factors Social Information Processing (SIP) model - How individuals process social cues across 6 stages Encoding of cues - Heightened attention to social rejection cues - Sensitive to negative emotions Interpretation of cues - Interpret ambiguous social scenarios as intentionally harmful - Self-defeating attribution style / bias - Rejection expectations Goal clarification - Prioritize avoidance goals (protection from rejection) over approach goals Response access and decision - Low social self-efficacy - Reduces engaging and increases reliance on avoidance strategies Behavioral enactment - Social awkwardness - Withdrawal - Inconsistent prosocial behavior Memory - Enhanced recall for both positive and negative social events - Increased false memories for non-social info o Attention to social cues might impair other cognitive processes Loneliness interventions - Improving social skills o But most lonely people have adequate social skills - Enhancing social support o Not long term - Increasing opportunities for social contact o Not the deeper subjective aspects - Addressing maladaptive social cognition (CBT) 21  o Most effective of these four o But only moderate effectiveness o Still elevated loneliness post intervention - Pharmacological o No approved medication for loneliness o Animal studies: SSRIs, neurosteroids, oxytocin Previous interventions - Complexity and diversity often overlooked o Viewing loneliness as unidimensional construct o Targeting only one contributing factor Pilot intervention - CBT based group intervention - More personalized approach o Personal social goals - Including more maintaining factors o Challenging maladaptive thoughts o Practicing interpersonal skills - Moderate decrease in emotional loneliness - No decrease in social loneliness - Still elevated levels of emotional and social loneliness Better alignment of loneliness interventions with specific subtypes But first need more research on underlying resilience and vulnerability factors of loneliness subtypes may identify better targets for effective interventions Vulnerability and resilience factors related differentially to subtypes - Emotional loneliness o Risk factors: symptoms of depression and social anxiety o CBT might be useful - Social loneliness o Resilience factor: secure attachment o Compassion focused therapy might be useful Barriers to treatment - Stigma - Hypervigilance to social threats - Healthcare providers lack training 22