Ptsd resolution5.2

PTSD research and statistics Bill Andrews Pragmatic Research NetworkSunday, 6 February 2011 1

PTSD treatment: the facts; outcomes of therapy Bill Andrews Pragmatic Research NetworkSunday, 6 February 2011 1

Bill Andrews Research Coordinator Pragmatic Research NetworkSunday, 6 February 2011 2The HGIPRN is expanding now to inclue and encourage a wider audience. The HGIPRN willforma sub-set of the total number of data contributors.

Bill Andrews Senior advisor ICCE www.centerforclinicalexcellence.comSunday, 6 February 2011 3The ICCE is a great resource.

What is PTSD? 1/6 DSM-IV-TR, APA, 2000Sunday, 6 February 2011 4

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, 2000Sunday, 6 February 2011 4

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, 2000Sunday, 6 February 2011 5

What is PTSD? 3/6 • C: Persistent avoidance of stimuli associated with the event(s) DSM-IV-TR, APA, 2000Sunday, 6 February 2011 6

What is PTSD? 4/6 • D: Elevated arousal that was NOT present prior to the event(s) DSM-IV-TR, APA, 2000Sunday, 6 February 2011 7

What is PTSD? 5/6 • E: The symptoms must persist for more than 1 month DSM-IV-TR, APA, 2000Sunday, 6 February 2011 8

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, 2000Sunday, 6 February 2011 9

Psychological TraumaSunday, 6 February 2011 10It’s easier to understand trauma on a continuum.

Psychological Trauma continuumSunday, 6 February 2011 10It’s easier to understand trauma on a continuum.

Psychological Trauma continuum physiological arousalSunday, 6 February 2011 10It’s easier to understand trauma on a continuum.

Psychological Trauma continuum physiological arousal PTSDSunday, 6 February 2011 10It’s easier to understand trauma on a continuum.

Psychological Trauma continuum physiological arousal acute stress disorder PTS PTSD anxiety depression addictionsSunday, 6 February 2011 10It’s easier to understand trauma on a continuum.

PTSD research and statisticsSunday, 6 February 2011 11

PTSD research and statistics • Scientiﬁc methodSunday, 6 February 2011 11

PTSD research and statistics • Scientiﬁc method • NICE guidelines (UK context)Sunday, 6 February 2011 11

PTSD research and statisticsSunday, 6 February 2011 13

PTSD research and statistics • Evidence hierarchySunday, 6 February 2011 13

PTSD research and statistics • Evidence hierarchy • RCTSunday, 6 February 2011 13

PTSD research and statistics • Evidence hierarchy • RCT • Meta-analysis of RCT studiesSunday, 6 February 2011 13

Meta-Analysis of Risk Factors for PTSD in Trauma-Exposed AdultsSunday, 6 February 2011 14

Meta-Analysis of Risk Factors for PTSD in Trauma-Exposed Adults 2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.Sunday, 6 February 2011 14

2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.Sunday, 6 February 2011 15Lack of social support is the greatest predictor of the risk of developing PTSD.

Predictors of PTSDSunday, 6 February 2011 16

Predictors of PTSD • lack of social supportSunday, 6 February 2011 16

Predictors of PTSD • lack of social support • post-trauma life stressSunday, 6 February 2011 16

Predictors of PTSD • lack of social support • post-trauma life stress • trauma severitySunday, 6 February 2011 16

• PTSD treatment NICE Guideline recommendationsSunday, 6 February 2011 17

• PTSD treatment NICE Guideline recommendations • Trauma- focused CBTSunday, 6 February 2011 17

• PTSD treatment NICE Guideline recommendations • Trauma- focused CBT • EMDRSunday, 6 February 2011 17

Trauma Focused TreatmentSunday, 6 February 2011 18The 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)Sunday, 6 February 2011 18The list.

Meta-analysis of PTSD treatmentsSunday, 6 February 2011 19

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, 2006Sunday, 6 February 2011 19

Meta-analysis of PTSD treatmentsSunday, 6 February 2011 20Agreement 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 traumaSunday, 6 February 2011 20Agreement 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 treatmentsSunday, 6 February 2011 20Agreement of no difference between trauma focused treatments.

Meta-analysis of PTSD treatmentsSunday, 6 February 2011 21Controversy over finding that in fact there is no difference between ANY studied treatmentsthat are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding

Meta-analysis of PTSD treatments • Benish et al, 2008Sunday, 6 February 2011 21Controversy over finding that in fact there is no difference between ANY studied treatmentsthat are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding

Meta-analysis of PTSD treatments • Benish et al, 2008 • NO DIFFERENCE in OUTCOMES between ANY bona fide treatments, WHETHER TRAUMA FOCUSED OR NOTSunday, 6 February 2011 21Controversy over finding that in fact there is no difference between ANY studied treatmentsthat are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding

TM c Bill Andrews 2010Sunday, 6 February 2011 22Let’s be pragmatic.

Practice Research NetworksSunday, 6 February 2011 23

Practice Research Networks www.hgiprn.orgSunday, 6 February 2011 23

Pragmatic Research Network TM c Bill Andrews 2010 pragmaticresearchnetwork.blogspot.comSunday, 6 February 2011 24The main purpose of a network is to try to investigate what is going on in practice.

Ask the Customers (n = 130)Sunday, 6 February 2011 25The data speaks for itself.

Ask the Customers (n = 130) !"#$%&( &()-+./0" 1234*56" &()*+," !" #" $!" $#" %!"Sunday, 6 February 2011 25The data speaks for itself.

Ask the Customers (n = 130) !"#$%&( !"#$%&( &()-+./0" &()-+./0" 1234*$!" 1234*56" &()*+," &()*+," !" #" $!" $#" %!" %#" !" #" $!" $#" %!"Sunday, 6 February 2011 25The data speaks for itself.

Ask the Customers (n = 130) !"#$%&( !"#$%&( &()-+./0" &()-+./0" 1234*$!" 1234*56" &()*+," &()*+," !" #" $!" $#" %!" %#" !" #" $!" $#" %!" !"#$ ()*.,/01" 234" ()*+,-(" !" #!" $!!" $#!" %!!" %#!" &!!" &#!"Sunday, 6 February 2011 25The data speaks for itself.

Ask the Customers (n = 130) !"#$%&( !"#$%&( &()-+./0" &()-+./0" 1234*$!" 1234*56" &()*+," &()*+," !" #" $!" $#" %!" %#" !" #" $!" $#" %!" !"#$ !"#$"% ()*.,/01" *+,-1/234" 234" 567.6" ()*+,-(" *+,-./0+" !" #!" $!!" $#!" %!!" %#!" &!!" &#!" !" #!" $!" %!" &!" !" (!" )!"Sunday, 6 February 2011 25The data speaks for itself.

Ask the Customers (n = 130) !"!#$%&(!% ()*+,01$ )*/$ 23245$6782$ .+/,+$ ()*+,!-$ !"#$ !"%$ !"&$ $ "!$ "$Sunday, 6 February 2011 26The effect sizes are large.

Ask the very distressed (n = 44)Sunday, 6 February 2011 27Clients seem to be moving to below the cut-off, even when the more distressed cohort arelooked at.

Ask the very distressed (n = 44) IES-E +,-.,/$" 0123456"47"89"1":"&&" +,-.,/#" !" #!" $!" %!" &!" !" (!" )!" *!"Sunday, 6 February 2011 27Clients seem to be moving to below the cut-off, even when the more distressed cohort arelooked at.

Ask the very distressed (n = 44) CORE-34 IES-E ()*+&,"-%" +,-.,/$" ./01234"25"67"/"8",," 0123456"47"89"1":"&&" ()*+&,"-$" +,-.,/#" !" #" $!" $#" %!" %#" &!" !" #!" $!" %!" &!" !" (!" )!" *!"Sunday, 6 February 2011 27Clients seem to be moving to below the cut-off, even when the more distressed cohort arelooked at.

Ask the very distressedSunday, 6 February 2011 28The data compares very favourably with one of the studies into PTSD from Northern Ireland.

Ask the very distressed Duffy et al n = 47 bdi conversion ()*+&,"-%" ./01"23"/."4"5",6" ()*+&,"-$" !" #" $!" $#" %!" %#" &!"Sunday, 6 February 2011 28The data compares very favourably with one of the studies into PTSD from Northern Ireland.

Ask the very distressed Duffy et al n = 47 Andrews et al n = 44 bdi conversion CORE-34 ()*+&,"-%" ()*+&,"-%" ./01234"25"67"/"8",," ./01"23"/."4"5",6" ()*+&,"-$" ()*+&,"-$" !" #" $!" $#" %!" %#" &!" !" #" $!" $#" %!" %#" &!"Sunday, 6 February 2011 28The 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 severitySunday, 6 February 2011 29

Likely Predictors of PTSD ResolutionSunday, 6 February 2011 30

Likely Predictors of PTSD Resolution • recognising the importance of social supportSunday, 6 February 2011 30

Likely Predictors of PTSD Resolution • recognising the importance of social support • teaching skills for management of post-trauma life stressSunday, 6 February 2011 30

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 traumaSunday, 6 February 2011 30

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 treatmentSunday, 6 February 2011 30

Meta-analysis of PTSD treatmentsSunday, 6 February 2011 31

Meta-analysis of PTSD treatments • NO DIFFERENCE between ANY of these trauma-focused treatmentsSunday, 6 February 2011 31

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 NOTSunday, 6 February 2011 31

Where Scientists AgreeSunday, 6 February 2011 32

Where Scientists Agree Possible Factors important to successful treatments of PTSDSunday, 6 February 2011 32

Where Scientists Agree Possible Factors important to successful treatments of PTSD • Therapists...ask yourself how many of these you can tick offSunday, 6 February 2011 32

Where Scientists Agree Possible Factors important to successful treatments of PTSD • Therapists...ask yourself how many of these you can tick off • Service Users...ask yourself how many of these have been honoured in your treatmentSunday, 6 February 2011 32

Possible Factors important to successful treatments of PTSDSunday, 6 February 2011 33

Possible Factors important to successful treatments of PTSD • Cogent rationale that is acceptable to patientSunday, 6 February 2011 33

Possible Factors important to successful treatments of PTSD • Cogent rationale that is acceptable to patient • Set of treatment actions consistent with the rationaleSunday, 6 February 2011 33

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 relationshipSunday, 6 February 2011 33

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 therapySunday, 6 February 2011 33

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 hopeSunday, 6 February 2011 33

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 • Identifying patient resources, strengths, survival skills and intra and interpersonal resources in building resilienceSunday, 6 February 2011 33

Possible Factors important to successful treatments of PTSDSunday, 6 February 2011 34

Possible Factors important to successful treatments of PTSD • Education about PTSDSunday, 6 February 2011 34

Possible Factors important to successful treatments of PTSD • Education about PTSD • Opportunity to talk about trauma if desiredSunday, 6 February 2011 34

Possible Factors important to successful treatments of PTSD • Education about PTSD • Opportunity to talk about trauma if desired • Ensuring the patients safety, especially if the patient has been vicitimized (domestic violence, neighborhood violence, or abuse)Sunday, 6 February 2011 34

Possible Factors important to successful treatments of PTSD • Education about PTSD • Opportunity to talk about trauma if desired • Ensuring the patients safety, especially if the patient has been vicitimized (domestic violence, neighborhood violence, or abuse) • Helping patients learn how to avoid re-victimizationSunday, 6 February 2011 34

Possible Factors important to successful treatments of PTSD • Education about PTSD • Opportunity to talk about trauma if desired • Ensuring the patients 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 efﬁcacySunday, 6 February 2011 34

Pragmatic ApproachSunday, 6 February 2011 35The Pragmatic Approach tries to ﬁnd a middle ground between the different sides of theargument.

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 YorkSunday, 6 February 2011 35The Pragmatic Approach tries to ﬁnd a middle ground between the different sides of theargument.

Pragmatic Research Implications for Innovative Psychological Trauma TreatmentsSunday, 6 February 2011 36

Pragmatic Research Implications for Innovative Psychological Trauma Treatments • Put the feedback of the service user at the top of the agendaSunday, 6 February 2011 36

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 measuresSunday, 6 February 2011 36

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 • Benchmark the results with published dataSunday, 6 February 2011 36

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 • Benchmark the results with published data • Map the innovative treatment onto existing approved treatmentsSunday, 6 February 2011 36

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 • 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 perspectivesSunday, 6 February 2011 36

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 • 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 controlSunday, 6 February 2011 36

Steve Hollon “ with respect to randomization I would paraphrase Churchill on democracy, that it is a terrible processthat has little to recommend it except that it is better than the alternatives” (Hollon, S. 2009)Sunday, 6 February 2011 37

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.Sunday, 6 February 2011 38Paul 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.Sunday, 6 February 2011 39

Prof. Gordon Turnbull Frontiers in Trauma Treatment BILL: What in your opinion are the significant breakthroughs in Trauma Treatment?Sunday, 6 February 2011 40

The New FrontierSunday, 6 February 2011 41

The New Frontier • unprocessed trauma memories control and cause exaggerated function of the ANSSunday, 6 February 2011 41

The New Frontier • unprocessed trauma memories control and cause exaggerated function of the ANS • PTSD is truly a MIND/BODY experienceSunday, 6 February 2011 41

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 therapiesSunday, 6 February 2011 41

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 therapySunday, 6 February 2011 41

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 • EFTSunday, 6 February 2011 41

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 • AcupunctureSunday, 6 February 2011 41

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 • AcupressureSunday, 6 February 2011 41

The New Frontier • Soothing the chaos in the right hemisphere • EMDR • MindfulnessSunday, 6 February 2011 42

The New Frontier • Using a treatment that works on soothing the ANS and works on the right hemisphere is likely to be a good ideaSunday, 6 February 2011 43

MedicationsSunday, 6 February 2011 44

Medications • Propranolol (lowering adrenaline) useful in the Acute Stress Reaction phase to reduce the ‘etching’ of the emotionally charged memoriesSunday, 6 February 2011 44

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 ﬂoodingSunday, 6 February 2011 44

AvoidanceSunday, 6 February 2011 45

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 ﬂashbackSunday, 6 February 2011 45

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 resistanceSunday, 6 February 2011 45

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’Sunday, 6 February 2011 45

Bill’s take home messageSunday, 6 February 2011 46

Bill’s take home message • have a healthy sense of curiositySunday, 6 February 2011 46

Bill’s take home message • have a healthy sense of curiosity • keep an open mindSunday, 6 February 2011 46

Bill’s take home message • have a healthy sense of curiosity • keep an open mind • systematically reﬂect on your workSunday, 6 February 2011 46

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 researchSunday, 6 February 2011 46

Bill’s take home messageSunday, 6 February 2011 47

Bill’s take home message • measure your outcomesSunday, 6 February 2011 47

Bill’s take home message • measure your outcomes • support research and/or get involved in case study research yourselfSunday, 6 February 2011 47

Bill’s take home message • measure your outcomes • support research and/or get involved in case study research yourself • be respectful of other modalitiesSunday, 6 February 2011 47

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 clientsSunday, 6 February 2011 47

Pragmatic Research Network pragmaticresearchnetwork.blogspot.comSunday, 6 February 2011 48

THE END www.centerforclinicalexcellence.com wandrews22@mac.comSunday, 6 February 2011 49

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Ptsd resolution5.2

by Bill Andrews on Feb 09, 2011

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