Trauma.docx

Trauma and associated psychopathology 1 September 2023 Dr. Caitlin Hitchcock Diagnosis, general considerations, and treatment options for: Posttraumatic Stress Disorder (PTSD) PTSD in Young Children (six years and younger) Complex PTSD 2 recent developments in diagnosis in PTSD which have been in...

Trauma and associated psychopathology 1 September 2023 Dr. Caitlin Hitchcock Diagnosis, general considerations, and treatment options for: Posttraumatic Stress Disorder (PTSD) PTSD in Young Children (six years and younger) Complex PTSD 2 recent developments in diagnosis in PTSD which have been instantiated in recent interactions of diagnostic manuals: PTSDYC (PSTD in Young Children) introduced in the DSM-5 Complex PTSD in the ICD 11 Both contentious/controversial – pros and cons of these different diagnoses - wants us to reflect on the strengths and limitations. What is a “trauma”? Definition has evolved over time – has become “looser” (to include vicarious trauma) 1st inception of PTSD Shellshock – post WWII – a result of war – orientated towards soldiers. As learn more about it, the definition of trauma has expanded. Important for understanding trauma over the lifespan: how what trauma is might vary over developmental stage (particularly in children) Criterion A, DSM-5 Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: directly experiencing the traumatic events, witnessing in person the event as it occurred to others, especially primary caregivers (vicarious trauma), learning that the traumatic event occurred to a parent or caregiving person. A key feature: is that there needs to be a perception of threat to physical integrity (includes sexual assault) or to life or serious injury. Trauma exposure is common. 31% of young people have experienced trauma by age 18 (Lewis et al., 2019, The Lancet). Using the DMS criteria of “trauma”. UK epidemiological study, a population representative sample Interpersonal trauma most commonly associated with PTSD. Direct and indirect e.g. inferred threat – car accidents; bike accidents, or medical incidents. A large proportion are “network” traumas – something happens to close friend/relative – particularly prevalent in trauma in young people andc children. Posttraumatic stress reactions Normal to have some sort of hyperarousal following a traumatic event Most reactions subside within one month of the event (so don’t do any diagnostic work until at least one month after the event) Symptoms after three months do not seem to change much, without treatment – peak in improvement but if not better by 3 months post event – is unlikely to get better – PTSD is a durable, chronic condition – durable in the symptoms don’t seem to fluctuate much like typically does with depression Hiller et al. (2016). Journal of Child Psychology and Psychiatry Top diamond is one month post trauma. Second diamond shifts – drop in symptoms (3 months) third diamond – not much change – see confidence intervals (cross zero). After a year barely any change. Showing no real change in symptoms over time – suggesting if don’t treat the PSTD they won’t get better. Diagnosis of PTSD Is a real difference between the ICD-11 (US/UK) and DSM-5 (Australia) in PTSD Changes in negative cognitions and mood (usually changes to negative cognitions/mood – negative self-concept) not required in ICD-11 but includes negative changes in cognition/mood in “complex PTSD” which incorporates. Impairment: must be getting in the way of life to be important – can sometimes be difficult to gauge (e.g., in cases of injury; childbirth; divorce; if avoiding/suppressing – can’t tell what life impacts are there e.g. might not have gotten in a car since an accident; if in an active war zone – situations of ongoing threat where have to get on with what doing – often won’t make a diagnosis in circumstances of ongoing threat b/c hyper vigilance might actually be functional) Will focus on DSM-5 – negative mood and cognitions was a major change in DSM-IV to DSM-5 DSM-5 Re-experiencing Avoidance Negative self-concept Arousal The traumatic event is persistently re-experienced as unwanted upsetting memories, nightmares, flashbacks. Emotional distress after exposure to traumatic reminders Physical reactivity after exposure to traumatic reminders Avoidance of trauma-related thoughts or feelings and external reminders of the event Overly negative thoughts and assumptions about oneself or the world Exaggerated blame of self or others for causing the trauma Low mood, decreased interest in activities, feeling Isolated Sense of being weak Irritability or aggression, risky or destructive behaviour Hypervigilance, heightened startle reaction Difficulty concentrating and/or sleeping Symptoms last for more than 1 month. Symptoms create distress or functional impairment (e.g., social, schoolwork). Risk factors for developing PTSD 30% of people will experience a trauma by time turn 18. Of them about 30% will go on to develop PTSD – so most people will be fine and so what differentiates those who naturally recover and those who have a chronic response? Direct interpersonal assault or threat most likely to develop PTSD. But does not mean that they will develop PTSD. Figure is showing risk factor for PTSD by trauma type: Highest risk is for those experiencing direct (whether or not also witnessed) interpersonal assault or threat. Lewis et al., 2019, The Lancet Are also personal level factors conferring greater risk of developing PTSD: Exposure to interpersonal trauma. Assigned female at birth. More disadvantaged socioeconomic conditions. Lower IQ. Children in foster care Higher incidence of previous trauma exposure and likelihood of future exposure, relative to general population Not all children in out of home care will have mental health difficulties: children who are in care are more likely to have experienced trauma (relative to the general population but that doesn’t mean they are more likely to experience mental health difficulties. Differentiation between experiencing trauma and the difficulties that might follow the trauma is very important to keep in mind. Recommendations for mental health assessment https://www.sciencedirect.com/science/article/pii/S0890856722003690 Trauma also creates risk for other disorders: Does having trauma increase risk of other disorders or does having PTSD increase risk of other disorders? Green lines – had trauma vs no trauma Red lines – PTSD vs no PTSD PTSD increases the risk of other conditions above and beyond the effects of having a trauma. These are odds ratios. Filled circles signify significance in which p<·05. Unfilled circles signify no significance in which p≥·05. ADHD=attention-deficit hyperactivity disorder. CD=conduct disorder. GAD=generalised anxiety disorder. MDE=major depressive episode. NEET=not in education, employment, or training. Perhaps those who develop PTSD and other disorders have less resilience. Marker could be that you’re more likely top experience trauma rather than more likely to experience PTSD https://uktraumacouncil.org/resources/childhood-trauma-and-the-brain “Brain development is much more than a story about biology from the earliest years. Relationships with others play a key role in shaping how our brain grows and develops. Early relationships where there is abuse and neglect have a long-term impact on children. A brain that has adapted to survive in a threatening or unpredictable world may not work so well in an ordinary environment. This can create what is called latent vulnerability, where early, abusive or neglectful experiences with carers put children at greater risk of experiencing mental health problems in the future. For these children, compared to their peers, common experiences like moving to a new school can feel more daunting and stressful. New faces can appear threatening. While positive social cues can be missed, it can be harder to negotiate new social situations and learn to trust new people. Even fun experiences like joining a new sports team, can be challenging. Too much focus on potential threat cues can mean missing out on positive social cues, such as at play or it causes an overreaction, which leads to an increased risk of conflict and sometimes violence. These reactions can increase the likelihood of generating new, stressful events. It's harder to deal with everyday challenges when you feel unconfident and anxious inside and harder to build and maintain relationships over time. This can mean a child loses friends and the support of adults, and so misses out on opportunities to grow and develop. This “social thinning” can increase the risk of mental health problems in the future. Neuroscience research is beginning to shed new light on how vulnerability unfolds over a child's life. All children need care and stimulation and adults who value them and who show them attention and love. These experiences shape a child's brain development. When children face traumatic experiences like abuse and neglect, their brain adapts to help them cope. We know of changes in three different brain systems: reward memory; and threat systems. Experiences of domestic violence or physical abuse can lead to hyper vigilance where the brain reacts more to threat. This might help a child stay safe in an early adverse environment, but it can cause problems in more ordinary environments. Hypervigilance can best be understood as a pattern of adaptation rather than a sign of damage. Abuse and neglect can also mean a world where a child's basic needs for care and attention are not met. This can shape the brain's reward system, the part of the brain that helps us learn about positive aspects of our environment and motivates our behaviour. Over time, the brain's reward system can learn to respond differently to things like positive social cues. Neuroscience studies have also pointed to changes in the autobiographical memory system. Our memory of everyday past experiences following trauma, negative memories appear to become more salient, which means they become more prominent than positive ones, and everyday memories can also become less detailed. This is a problem because we need to draw on past experiences to help us deal with new social situations. Neuroscience research is showing how childhood trauma can create latent vulnerability, increasing the risk of later mental health problems like anxiety and depression. This vulnerability is not just located in the child, but arises through their relationships. Helping children who have experienced trauma still requires ordinary boundaries and consequences, but it also requires us to step back and reflect and see behaviour that we find challenging in a different light. A child may simply be doing their best to survive now with brain adaptations from the past. We know a child's brain has the capacity to continue to adapt for this to happen. They need our help to build and maintain trusted relationships, manage everyday stresses and prevent new ones from happening. We need to encourage them to try again and believe things can be different. This is far from an easy task and takes time.” Science is helping reframe our understanding of childhood trauma. Seeing children's behaviour in a new light can mean we respond differently, but there is much still to learn. Working together, we can develop more effective approaches that promote resilience and recovery. We can help Children build trusting relationships and create opportunities for their brains to adapt in new ways. Understanding and treating PTSD Hiller, Hitchcock, & Cobham (2020) Oxford Handbook of Traumatic Stress Disorders Assessing for PTSD – self report Assessing for PTSD – Interviews: Why does PTSD develop? There key domains where changes are implicated in the development of PTSD: reward, memory, and threat systems – we will focus on MEMORY: nature of the trauma memory = and important component of predicting prognosis and of therapy to ameliorate systems Ehlers and Clark (2000) model: places the processing and memory system as central in explaining why a person might develop PTSD post a traumatic event Nature of the trauma memory is a very important part of prognosis and treatment approach. Risk factors include female gender; characteristics of trauma – biological and neurological underpinnings that predispose a person for PTSD(not discussed today) – we will focus upon the cognitive factors. Evidence suggests that how an event is processed is important in increasing the likelihood of PTSD. Most of the processing we do is via our autobiographic memory: memory for personal life experiences. Overall tenant of the theory is that there is a distorted quality to the memory of the event. Might be due to: Factors present which impact how the event is understood Nature of threat cues Memory is fragmented – no clear coherent narrative structure (no clear beginning, middle and end; its disjointed and fragmented – and so hard to make sense of it. Might be particular moments or hotspots (I was going to die) – which creates maladaptive reappraisals and can cause memories to re-occurring as brain tries to make meaning from the event. Brain can’t file it away and leave it in the past – brain continues to try to make sense of it – will keep bringing it back (intrusive memories and the feeling of fear etc). Intrusive memories and the feeling of being in threat and so heightens threat responses. The individual then engages in strategies to try to minimise that response e.g., avoidance, distraction. More avoid the less can learn that it can/will go away - a vicious cycle – keeps looping back. Lots of research that each of the components are supported at a causal level. Arrows going back up to the top – a vicious cycle. https://davidtrickey.com/resources Try to fit the experience to the model: Case example: Ali (64yo) Elthers & Clark 2000 Case example: Imran (6 yo) Imran was in the back of the car: how might his experience be different - he thought maybe his singing caused the accident. He was strapped in his seat, alone and couldn’t see what was happening. Generalised to any car – worried that if he gets in any car, something will happen – but don’t have any choice, less control over avoidance strategies in particular Both were in Caitlin’s clinic for treatment Treatment Must be evidence-based Must be delivered by a qualified mental health professional Needs to be recommended by National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/guidance/ng116/chapter/Recommendations#management-of-ptsd-in-children- young-people-and-adults Medication not recommended – psychological intervention is the frontline for children in particular – trauma focussed CBT Key features of Trauma-focused CBT In its essence trauma-focussed CBT focusses upon the distorted memories and to improve processing and making meaning in association with the trauma in a way that helps to have functional response to the trauma compared to the maladaptive symptoms that someone is having. Focusses upon making meaning and functional interpretation of the trauma Not clear whether the include the caregiver – here the grandfather was also dealing with his own PTSD – might be promoting some the responses of the child. Even if not there, they might still have responses Treatment – unclear whether should involve caregivers Individual patient data meta-analysis Top line – involved the caregiver in treatment – bottom line did not involve caregiver – Confidence Interval’s overlap suggesting is not a significant difference in efficacy of treatment when compare treatment when caregivers are involved to when they are not involved. So, decide on a case by case basis. Eye Movement Desensitization and Reprocessing (EMDR) Therapy Second line treatment used only if the trauma-focussed CBT did not work Patient focusses on the trauma memory while experiencing bilateral stimulation, typically as eye movement. Adaptive Information Processing model (Shapiro, 2007) proposes that EMDR aids processing of trauma memory. Exact mechanism of action unknown (see van den Hout et al., 2011) EMDR suggested as a treatment for PTSD in children who do not respond to CBT (NICE guidelines) – second lone of treatment. ALWAYS START WITH TRAUMA CBT More general considerations for supporting trauma exposed children. Listen and talk about the trauma, if the child raises it: if a child brings it up, it’s ok\ good to talk about it (promotes shame; avoidance to not talk about it etc) Beware of situations which might trigger symptoms. Provide clear boundaries and expectations (helps to make the world predictable and safe). Routine, predictability, consistency in responses, rules etc, are all very important. Support emotional management and regulation. Recognise it’s ok to feel upset etc SPECIAL APPLICATIONS: PTSD in young children (3-8 years old) - PTSDYC Children are likely to blame themselves as meaning making is more difficult for them. A lot of early diagnostic criteria was very focussed on an adult model – but know for children PTSD will be a different experience particularly in young children. Traditional PTSD criteria does not identify PTSD young children. When use adaptive criteria (developmentally appropriate criteria significantly increases identification of children with functionally impairing PTSD. Data shows the developmentally appropriate criteria in older ages - symptoms getting in the way of functioning. Exposure work for little children focusses more upon memory focussed rather than taking a child back to the scene of the trauma PTSD in Young Children (3-8 yrs old) PTSD poorly identified in young children due to early focus on war induced PTSD so adult focused. But there are some developmental considerations that impact on different trauma symptoms might be demonstrated and experienced by children. DSM-IV PTSD criteria DSM PTSD criteria for children ≦ 6yrs Traditional criteria are very poor at identifying children <10 year with PTSD. Not a single child was identified using the adult criteria. But when use adapted (developmentally appropriate criteria), more children are identified who are experiencing functionally impairing PTSD. Seen in the general population and in children in the welfare system. Criteria adapted by DSM-5 to apply to children 6 years and younger but the data from the above study shows that developmental considerations at play across the trajectory – the adapted criteria might be better used up into adolescents. The adapted criteria places less emphasis on avoidance – kids don’t have the power/control to avoid. Also, cognitive aspects – can be difficult to measure the negative self-concepts in little children as their negative articulation is still developing – less focus on cognitive symptoms and more on behaviour symptoms. So rely more on what a care giver can observe, than relying on self-reporting, and more consideration over what they do and do not have control over. DSM-5 PTSD in Young Children (≦6yo) subtype (PTSDYC) Re-experiencing Avoidance Negative self-concept Arousal The traumatic event is persistently re-experienced as unwanted upsetting memories, nightmares, flashbacks Emotional distress after exposure to traumatic reminders Physical reactivity after exposure to traumatic reminders Avoidance of trauma-related thoughts or feelings and external reminders of the event Only symptom one needed Overly negative thoughts and assumptions about oneself or the world Exaggerated blame of self or others for causing the trauma Low mood, decreased interest in activities, feeling isolated Irritability or aggression, risky or destructive behaviour Hypervigilance, heightened startle reaction Difficulty concentrating and/or sleeping Traditionally these children are poorly identified or rarely are treated (<10%). So, Hitchcock et al developed a CBT manual with a trauma focussed processing component with the 3 components: memory, meaning and management. So taking the evidenced based empirically supported model of PTSD (Ethyl and Clarke model) and design a treatment that is developmentally appropriate which targets each of those areas that are keeping the symptoms going. CBT-3M for young children with PTSD Therapists are often very hesitant to use memory focussed exposure work – but we know from causal longitudinal studies must do the memory focussed exposure work to help someone have a cohesive memory and to have a a strong narrative structure around the event/memory– PTSD is often thought of as a memory disorder because it feels like the memory is ongoing. The hyper-vigilant arousal response is telling you that the danger event is ongoing – the threat is here and now not in the past. Trauma focussed exposure work helps to put it into the past sop can move forward. With adults will often do prolonged exposure – talk them back through the events – this can be very difficult with young children – need a different approach. Used lego - re-enacting through play – try to update the meanings attributed to the event and to put a beginning, middle and end – to create a clear structured narrative. Help to draw in helpers that the child didn’t know were there: update the meaning within that ie that the child wasn’t actually alone when they thought they were Treatment efficacy established Exposure-trauma focus CBT has been shown to be successful in reducing PSTD symptoms and in fear and in identification of emotions more generally which is important for development. SPECIAL APPLICATIONS: Complex PTSD Not in the DSM-5 – but is in the ICD-11 PTSD (World Health Organization). ICD-11 has maintained the 3 core criteria (A): PLUS the bottom set (B) DSM has the criteria in A and the additional 3 criteria in the lower half of B. Is a lot of debate as to whether complex PTSD is different from PTSD or is just a more severe form of PTSD. Factor analysis supports distinction of complex PTSD from “ordinary” PTSD. However, diagnostic reliability less well explored in children relative to adults. One of the key distinctions of complex PTSD is affective numbing or over-reactivity – is about dissociation: feeling detached from own body, as if you were observing yourself (world feels unreal, like in a dream). Is a persistent experience of disconnection. It is not common to have complex PTSD after a single traumatic event – CPTSD generally after chronic/repeated abuse/violence. Because autobiographical memory not in place before age of 2 and other limitations on understanding/meaning making, are young children more likely to experience CPTSD from a single event. The evidence is no. Elliott et al looked at whether for young children, repeated trauma may not be necessary. Study did not find an increased likelihood of complex PTSD following a single event in young children. “Complex trauma” is either repeated trauma or a number of different types of trauma – needs to be one or both of these things – and if is complex trauma, it is more likely to lead to complex PTSD (than single incidence complex trauma) Complex PTSD more common in complex trauma Complex trauma Experience of trauma which is: repeated occurrence and/or varied trauma types Regardless, if is PTSD or CPTSD, trauma focussed CBT is the best approach. The same treatment helps regardless of the label given to it. A lot of people say should do stabilization work first but there is no evidence that this helps – don’t need a long lead in period. Take home points. Childhood trauma exposure is common, childhood PTSD is not. Beware of the wider impact of trauma on the child. Preschool aged children can experience PTSD (traditionally people have not focussed on this, but it needs to be acknowledged and treated). Complex PTSD supported by factor analysis, but diagnostic reliability and validity needs further evaluation. Trauma-focused CBT the recommended treatment for both PTSD (in children of all ages) and Complex PTS. DISCUSSION What is a trauma? Can be different for a child vs for an adult. PTSD looks different in children but it is still treatable. Safety: mum’s safety; safety of the home. More traumatic as came from someone she knew and perhaps perceived as safe. Is this a trauma? It is about perceived threat. It is the perception of threat that makes the effect traumatic for the child even if it was an accident. What would PTSD in a 4-year-old look like? As clinicians a key task is trying to fit the theory of what you know is causing someone’s difficulties to that person’s experience so can explain to them what is going and can identify points of intervention. Use exposure based memory work to identify the cognitions driving her behaviours. What might get in the way of completing exposure-based treatment with kids? Exposure work with children What clinician-based factors might influence treatment delivery? Staying focused; high levels of distress; building trust/rapport; need for another support person; clinical setting itself; parents might be very hesitant; question qualifications etc., parental fear/guilt/protective. Clinician: concern that might do harm; voyeurism. Clinician thinking “unconditional positive regard” is required but it is not necessary – child needs to How might this impact the child’s recovery? Increasing anxiety; may want to avoid engaging because its so effortful; clinician re-engaging What would you say to someone who was hesitant to complete exposure? Evidence is that without treatment, won’t be resolved and that exposure treatment is the most effective way of resolving