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Ptsd a psychological perspective 92911


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Ptsd a psychological perspective 92911

  1. 1. PTSD: A Phychophysiological Perspective Carmen V. Russoniello, PhD., LPC, LRT, BCB, BCN Director, Psychophysiology Lab and Biofeedback Clinic East Carolina University
  2. 2. DisclosureIn the spirit of full disclosure I acknowledge that I currently serve onthe Scientific Advisory Committee of Biocom Technologies (unpaid)and own a small percentage of the company stock .
  3. 3.
  4. 4. Kilo Company 3rd Battalion 26th Marines Namo Bridge Fall, 1969
  5. 5. “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” -Charles Darwin
  6. 6.  The overall goal of the ECU Wounded Warrior Program is to increase performance and promote functional independence.  The program involves methods to help Marines learn how to control physical and emotional reactions to stress (resiliency), as well as techniques to increase strength, endurance, cognitive performance, social and life skills.  The program involves sessions both at Camp Lejeune and at the Biofeedback Clinic at East Carolina University.
  7. 7. PTSDWhen a person is exposed to extremestress such as sexual abuse, war, or eventhe extended effects of a natural disaster,clinically significant symptoms oftenemerge.
  8. 8. The existence, frequency,intensity, and duration of thesesymptoms are dependent uponmany factors, including, gender,age, and ethnic background ofthe person exposed to thestressor as well as the person’ssocial environment and ability toemploy coping strategies.
  9. 9. Specific emotional and behavioralresponses to stress have beenobserved and studied by mentalhealth professionals in multiplesettings, under differentcircumstances, over time. Thesesymptoms have become the clinicalindicators used for identifying thestress related disorder known asposttraumatic stress disorder(PTSD).
  10. 10. APA categorizes PTSD symptoms intothree main clusters:1.A traumatic event that ispersistently re-experienced;2.A persistent avoidance of stimuliassociated with the trauma and3. A numbing of generalresponsiveness and persistentsymptoms of increased arousal. Thesymptoms must last at least onemonth and adversely affect normalfunctioning.
  11. 11. “the development of characteristic andpersistent symptoms along with difficultyfunctioning after exposure to a life-threatening experience”. These persistent,post trauma symptoms were the basis forthe development of the original PTSDdiagnosis in 1980 and with somemodification still serve as the diagnosticcriteria. While this classification system is auseful is has some limitations such as theexclusion of some less common cognitive,emotional, behavioral and physiological-somatic symptoms.
  12. 12. • Inescapable Shock• Autonomic Nervous System• Sympathetic• Parasympathetic• Learned Helplessness• Defense Defeat Model• Possible bipolar effect with parasympathetic becoming dominant and then sympathetic rather than rhythmic
  13. 13.  Exposure of rhythmic environments to chemical or behavioral stressors can result in increases and decreases in the response (Antleman (1996, 1997) Possible innate biological function designed to reset the rhythm
  14. 14.  Sympathetic Dominance can produce: muscle bracing, bruxism, occular divergence, tachycardia, diaphoresis, pallor, tremor, startle, hypervigilance, panic rage and constipation
  15. 15. • Symptoms of palpitations, nausea, dizziness, indigestion, abdominal cramps, diarrhea, and incontinence• Self perpetuating symptoms causing continued dysregulation “free falling” “The syndrome of trauma has now literally taken control of the body”
  16. 16.  The ANS plays an important role in the development and maintenance of a wide range of somatic and mental diseases In general autonomic imbalance and decreased parasympathetic tone may be the final common pathway linking negative affective states and ill health (Thayer & Brosschot, 2005)
  17. 17.  Symptoms of dissociation mimic the bipolar nature of the defining symptoms of PTSD (arousal, reexperiencing, avoidance).
  18. 18.  Altered perception of time, space, sense of self and reality. Emotional Expressions can range from panic to numbing and catatonia. Altered sensory perceptions may vary from anesthesia to analgesia to intolerable pain. Motor problems include weakness, paralysis, and ataxia as well as tremors, dysarthia, shaking, and convulsions.
  19. 19.  Cognitive Symptoms include confusion, dysphasia, dyscalculia, and extreme attentional deficits. Perceptual symptoms include ignoral and neglect Memory alterations may appear as hyperamnesia (Flashbacks), fugue states or selective traumatic amnesia.
  20. 20.  Endogenous opiate reward systems contribute to the establishment of conditioned procedural memory in trauma. Exposure to war trauma often results in a sustained period of analgesia (soldiers in wounded in battle require lower doses of morphine than in other non-combat related wounds) Stress can induced analgesia in many forms of trauma
  21. 21.  Relates to facts and events Plays an important role in conscious recall of traumatic events) Involves the hippocampal and prefrontal cortical pathways (inaccurate and subject to decay)
  22. 22.  acquisition of new motor skills and habits to the development of emotional memories and associations, and to the storage of conditioned sensorimotor responses. Unconscious, implicit, and extremley resistant to decay when linked to emotional or threat based interventions. (Scaer, 2001)
  23. 23.  Surgical Revolution  Anesthesia introduced in 1846 Antibiotic Revolution  Penicillin introduced in 1941 Endogenous Factor Revolution  Personal healing  Attacking germs and more importantly “Bad Habits”
  24. 24. Walter Cannon (1896)  Coined “flight or fight response” to stress  developed concepts of mind/body model  Emphasized the importance of the parasympathetic systemSelye (1975) General Adaptation Syndrome Stages alarm reaction resistance exhaustion
  25. 25. The Defense/Defeat Model fight or flight immune system suppressionFolkow (1993)
  26. 26. “environmental demands tax or exceed the adaptive capacity of an organism, resulting in psychological or biological changes that may place persons at risk for disease.”Cohen, Kessler & Gordon (1995).Measuring Stress
  27. 27.  “Technically speaking, a stress reaction is a mental and physical response to an adverse situation that mobilizes the body’s emergency resources, the flight or fight mechanism, which floods the body with hormones that arose to meet the challenge. Unfortunately modern life continually triggers this response when we can neither fight or flee, which can lead to chronic heightening of blood pressure and muscle tension, irritability, anxiety, and depression-and a lowering of immune effectiveness”. (Daniel Brown, 2003. Stress, Trauma and the Body, p. 89).
  28. 28.  Stress enhances susceptibility to disease Both psychosocial & biological stressors evoke the flight or fight response Stress Disinhibition Theory  People engage in a broad range of dysfunctional behaviors as a result of stress
  29. 29.  commonplace stressful events produce immunological alterations chronic stressors have been linked to the longer-term down-regulation of immune function immunological changes have negative consequences for health Lonely Person with a Kind Heart
  30. 30.  Endocrine system  facilitates communication between the mind and body  acts as an internal intelligence carrying information that regulates the organism  receptors for catecholamines (adrenaline) in immune cells  nerve fibers go "into virtually every organ of the immune system and form direct contacts with the immune system cells“ (Ader, 1993).
  31. 31. The Defense/Defeat Model fight or flight immune system suppressionFolkov (1993)
  32. 32.  The central nervous system that regulates the ANS balance is called the central autonomic network (CAN). The CAN work with networks to regulate the following functions: Executive Social, Affective Attentional Motivational
  33. 33.  When negative Inhibitory or circuits are negative Autonomic, compromised processes or cognitive, and positive circuits feedback affective function develop and result circuits that assist humans in hypervigalance. permit maintaining The symptoms can behavior andbalance in the face be devastating and redeploy of environmental if not ameliorated resources challenges can develop into needed permanent elsewhere conditions
  34. 34.  A common subcortico neural system regulates defensive behavior including autonomic, emotional and cognition When prefrontal cortex is taken “offline” for whatever reason parasympathetic inhibitory action is withdrawn and relative sympathetic dominance associated with defensive occurs This can be measured by assessing parasympathetic contribution to overall HRV
  35. 35.  Growing evidence supports the use of HRV as a predictor of hypervigilance and inefficient allocation of attentional and cognitive resources (Thayer & Brosschot, 2005)
  36. 36.  “Autonomic Imbalance and Decreased Parasympathetic Tone in particular may be the final common pathway linking negative affective states and dispositions, including the indirect effects via poor lifestyles, to numerous diseases and conditions as well as increased mortality, and it may also be implicated in psychopathological conditions”.
  37. 37.  Low HRV is associated with the following conditions cardiac symptoms of panic attack Poor attentional control Poor emotional regulation Behavior inflexibility Friedman and Thayer, 1998
  38. 38.  Depression (Thayer et al., 1998) Generalized anxiety disorders ( Thayer et al, PTSD (Cohen et al., 1999) Cardiovascular morbidity and mortality Diabetes (Ziegler et al., 2001)
  39. 39.  Immune deficiency and inflammation contributing to:  Aging  CVD  Osteoporosis  Arthritis  Alzheimer’s  Periodontal disease  Certain types of cancers as well as muscle decline increased frailty and disability
  40. 40.  The overall objective of Heart Rate variability training is to decrease ANS hyperarousal and improve its balance. Wounded Warriors learn to control ANS responses to stress producing stimuli such as thoughts, memories and images associated with combat. Decreasing arousal and maintaining ANS balance for increasing lengths of time is the goal of training.
  41. 41.  Once it was observed that alpha waves were dysfunctional in vulnerable populations protocols were developed to help people learn to train alpha and theta waves as a method of improving function. Peniston and Kulkosky showed increased alpha and theta brainwave production resulted in normalized personality measures; and prolonged prevention of relapse in alcoholics. The protocol has also showed efficacy as an intervention in drug addiction, depression and PTSD.
  42. 42.  The graded stress exposure training program used in this study is one month in duration and consist of a pre assessment, 16 biofeedback sessions (four per week) a post session evaluation and a 3 month follow up. Each week participants will be exposed to increasing stress producing stimuli: 1. Stroop Color Word Test, Math Stressor; Talk Stressor/Everyday Events 2. Talk Stressor/ Combat Experiences; 3. Images and Sounds of Combat; 4. Virtual Baghdad or Afghanistan (virtual reality exposure).
  43. 43.  Each biofeedback session consists of 5 minutes of baseline followed by 5 minutes of the weekly stressor, followed by 20 minutes of HRV and neurofeedback training, followed by 5 minutes of the stressor; followed by 20 minutes of HRV and neurofeedback and finally 5 minutes of recovery data.
  44. 44.  Preliminary clinical data collected so far indicate decreases in ANS hyperarousal and increases in parasympathetic activity. Reports on PHQ-SF 36 indicated positive changes in physical symptoms, and decreases in depression panic attack and anxiety.
  45. 45.  Heart rate variability training changes Neurofeedback The Posttraumatic Stress Checklist (PCL) Deployment and Resilience Patient Health Questionnaire short form (PHQ SF-36) Profile of Mood States Salivary alpha-amylase (sAA) changes. Behavioral questionnaire assessing alcohol, drug, nicotine use, nutrition habits etc. Self satisfaction inventory
  46. 46.  Dysfunction in ANS and CNS flexibility and balance are associated with symptoms of PTSD in combat veterans. Methods that are designed to restore balance in these systems are needed to ameliorate these symptoms. Biofeedback/Neurofeedback is a safe method to achieve these goals.
  47. 47.  To create an awareness and understanding of the components of effective health improvement programs. To explore the specific application of health applications in the treatment of PTSD, anxiety, and depression.
  48. 48.  Define the treatment components of health improvement programs and their prescriptive parameters  Review specific health improvement protocols for PTSD, Anxiety and/or Depression
  49. 49.  The greatest revolution of our time is the knowledge that human beings, by changing the inner attitudes of their minds, can transform the outer aspects of their lives. -William James
  50. 50.  Exercise and Body Awareness Nutrition Stress Management Mental Focus Relaxation-meditation- and other antidotes to stress (recreation/physical activity)The overall focus is on positive behavioral change and coping.
  51. 51. The first requirement necessary for change is that you want to change!We are all in different STAGES with respect to multiple behaviors in our lives.
  52. 52. DEFINITIONS: Precontemplation  Someone in this stage probably has no intention of making change or adopting healthier habits. Contemplation  Someone in this stage realizes the importance of specific changes. They may be thinking of making some behavioral changes in the next six months. Preparation  Someone in this stage is ready to make some behavioral changes. They may already engage in some health behaviors some of the time but it is just not something they do regularly. Action  Someone in this stage has overcome all the obstacles and have integrated behavioral changes but haven’t been doing it very long . They are doing it! (e.g., They are physically active on a regular basis– less than six months). Maintenance  Someone in this stage is has integrated the behaviors on regular basis and has maintained these for more then six months.
  53. 53. Precontemplation Example: Learn about all the benefits of being physically active. Start thinking about what being physically active could mean for you.Contemplation Example: Remind yourself all the benefits you will get from being active. Picture yourself healthier and more energetic than ever before. Try to record your progress and improvements and make sure you have support from family and friends.
  54. 54. Stages of ChangePreparation  Set a start date.  Tell everyone you know.  Establish priorities.  Make the change a high priority in your life.  Leave no room for excuses.
  55. 55. Action Example: Participate in activities that are not effected by the weather- join an exercise class or indoor sports league. Make physical activity a priority. Plan physical activity in your daily schedule. Make sure your family and friends know how important physical activity is to you.
  56. 56. Stages of ChangeMaintenance Maintain your behaviors. Reinforce yourself. Examples: Try a new activity or sport. Vary your walking or cycling path. Change the music you walk to. Be active at different times during the day.
  57. 57. Each level of the activity pyramid isimportant in helping you increaseyour physical activity level andoverall health. Each day you shouldtry to participate in a variety ofphysical activities. Remember not tolimit yourself to one type of activity.
  58. 58. DEFINITIONS OF ACTIVITY PYRAMID LEVELSAerobic Exercise: Aerobic exercise improves cardiovascular fitnessand makes your heart and lungs stronger (3-5X/wk.). Recreational Activities: Recreational activities may also improvecardiovascular efficiency or more simply said will make your heartand lungs strong (2-3X/wk.). Leisure Activities: Leisure activities are low-level enduranceactivities. Flexibility and Strength: Flexibility activities help to increase andmaintain muscle flexibility. Strength exercises can help improvemuscle strength (2-5X/wk.). Sedentary: The top level of the pyramid signifies sedentary life. Thisis the smallest part of the pyramid and the activities here should takeup the smallest amount of your leisure time.
  59. 59.  Identify your personal activity levels based upon the activity pyramid. Estimate the types of activities you do on an average week.
  60. 60.  The purpose of this activity is to demonstrate the many inherent benefits of a recreational activity  Think social, emotional, cognitive, physical, and spiritual.  Bingo:  Swimming:  Gardening:  Arts & Crafts:  Scuba Diving:
  61. 61.  Goals  Assist the patient/client create an awareness of current nutritional patterns.  Provide information to assist Marines/clients in identifying healthy and unhealthy nutritional choices.  Assist Marines/clients in implementing strategies to change unhealthy nutritional patterns
  62. 62. Key Nutrients Milk and Milk Products Calcium Meat and Meat Alternatives Protein Iron Vegetables Folic Acid Vitamin A Vitamin C Fruits Folic Acid Vitamin A Vitamin C Breads and Cereals: Complex Carbohydrates  FiberServings From The Food Guide PyramidMilk, Yogurt, and Cheese: 1 cup of milk or yogurt, 1 1/2 ounces of natural cheese, 2 ounces of processcheeseMeat, Poultry, Fish, Dry Beans, Eggs, and Nuts: 2-3 ounces of cooked lean meat, poultry, or fish, 1/2 cupof cooked dry beans, 1 egg, or 2 tablespoons of peanut butter count as 1 ounce of lean meatVegetables: 1 cup of raw leafy vegetables, 1/2 cup of other vegetables, cooked or chopped raw, 3/4 cup ofvegetable juiceFruit: 1 medium apple, banana, orange, 1/2 cup of chopped, cooked, or canned fruit, 3/4 cup of fruit juiceBread, Cereal, rice, and Pasta: 1 slice of bread, 1 ounce of ready-to-eat cereal, 1/2 cup of cooked cereal,rice, or pasta
  63. 63. •Daily Servings and Guidelines•Food Labels•Calculating Calories
  64. 64. North Carolina State University A&T State University Cooperative ExtensionNorth Carolina Governor’s Council on Physical Fitness and HealthPace University Made possible through a grant from Child Nutrition Services, the State Board Of Education and the Department of Public Education.
  65. 65.  There is a need to identify automatic thoughts and patterns before intervention begins.  One effective method is to have the client/patient record a daily record of automatic thoughts ( A positive and negative thought diary!).
  66. 66.  Can you name any?
  67. 67. 1. All-or-nothing thinking2. Overgeneralization3. Mental filtering4. Disqualifying the positive5. Jumping to conclusions  Mind Reading  Fortune telling
  68. 68. 6. Magnification and minification7. Emotional Reasoning8. Labeling9. Personalization10. “Should Statements”
  69. 69.  Challenge Automatic Thoughts Clarify the Problem and What Can Be Done Taking Small Steps The Three “Cs” (‘Four)  Commitment  Control  Challenge  and Closeness
  70. 70.  The Relaxation Response  Mini-Relaxation Response The Quieting Response Autogenics Imagery
  71. 71.  Anxiety PTSD
  72. 72.  Each one to two-hour session includes a relaxation exercise, stretching and body awareness exercises, data collection, didactic presentation, experiential exercises, and self help assignments to reinforce skill development. Theses protocol is applicable to PTSD, Anxiety disorders and most depressions. Contraindications include individuals who are actively suicidal, psychotic or otherwise unable to comprehend the presented information and ormanage their own care.
  73. 73.  Each one hour session includes:  a relaxation exercise,  stretching and body awareness exercises,  data collection,  didactic presentation,  experiential exercises and  self help assignments to reinforce skill development.
  74. 74.  The protocol is applicable to:  generalized anxiety,  panic attacks or  specific phobias such as social phobias
  75. 75. Contraindications include individuals who are: actively suicidal, psychotic, unable to comprehend the presented information, or unable to manage their own care
  76. 76. Session I The MindBody Connection Physiology of Stress Changing Behaviors Session II Relaxation Response Diaphragmatic Breathing
  77. 77. Session III Benefits of Distraction Developing Mental Focus Session IV Benefits of Exercise Movement/body Awareness Developing Mindfulness
  78. 78. Session V Stress Warning Signs Automatic Thoughts Session VI Attitudes, Beliefs, and Assumptions Stress Hardiness Cognitive Restructuring Skills
  79. 79. Session VII Awareness and Choice Moods, Feelings, and Emotions Effective Coping & Problem Solving Session VIII Social Support Self-Esteem Effective Communication
  80. 80. Session IX Relapse Prevention Setting Realistic Goals Session X Review: Stress Hardiness Community Resource
  81. 81.  Effects of treatment and the disorder may produce symptoms (anxiety, depression, physical dysfunction)
  82. 82. Designed to help Marines deal with PTSD symptomsDesigned to teach Marines how to take an active role in their healthcareDesigned to help Marines become resilient to stress
  83. 83. Session I The MindBody Interaction Physical, Emotional, and Cognitive Effects of Stress Psychoneuroimmunology and other MindBody Research Introduction to the Relaxation Response Use of Recreational Activities Characteristics of Long-Term Survivors
  84. 84. Session II The Importance of Exercise Diaphragmatic Breathing Yoga/Body Awareness Nutrition Information Session III Stress Hardiness Control, Commitment, Challenge, Caring Short and Long term Goal Setting
  85. 85. Session IV Cognitive Restructuring Recognizing Negative Automatic Thoughts Challenging Automatic Thoughts Using Positive Affirmations Session V The Immune System Using Imagery
  86. 86. Session VI Recognizing emotions (Journal Writing) Dealing with Emotions of Fear, Anger, Depression, and Guilt Family Patterns of Expressing Emotions Session VIII Communication with Family and Health Care Providers How My Diagnosis Affects Others
  87. 87. Session IX Living with Uncertainty Physical Self-Care Habits Support Networks Attitudes and Beliefs Action Skills to Change theSituation Life Experiences That Will Help
  88. 88. Session X Humor as a Coping Strategy (CousinsTribal Rituals) Recreational Activities Program Debriefing Staying Motivated Reflections and Thoughts to Remember Celebrate Life
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