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Treatments for Psychological Trauma: From Acute PTSD to Chronic Traumatization James L Spira, Ph.D.,


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Title: Treatments for Psychological Trauma: From Acute PTSD to Chronic Traumatization James L Spira, Ph.D.,

Treatments for Psychological Trauma From Acute
PTSD to Chronic Traumatization James L Spira,
Ph.D., MPH, ABPPClinical Professor, Department
of Psychiatry, UCSDClinical Director, Casa
Palmera Residential Treatment Facility
  • Part 1 Understanding Trauma and Trauma Tx
  • Part 2 Clinical Methods Which Can Be Easily
  • Used
  • Part 3 Applications to Counseling Center
  • Settings with Non-specialized Staff

Outline , Part 1
  • Types of Trauma
  • Psychophysiology of Trauma
  • Predispositions to Develop Trauma
  • Traditional Treatments and Efficacy
  • Recent Developments in Treatment and Improved
  • Adapting Methods for Therapy with Students

Types of Trauma
  • Recent Single Event
  • ASD (dissociative and hypervigilant qualities)
  • PTSD Acute (hypervigilant and avoidant qualities)
  • PTSD Chronic ( gt 3 mo)
  • Complex Acute PTSD
  • Other co-existing psychological or physical
  • Complex Chronic PTSD/Trauma
  • Ongoing Childhood Abuse, by caregiver
  • Adolescent
  • by authority figure
  • by partner
  • Delayed PTSD

Types of Trauma
  • Childhood chronic abuse
  • Not necessarily fitting PTSD Criteria
  • Involved in personality development
  • Understanding of relationship and sexuality
  • Bonding Difficulty
  • Avoidant or anxious attachment
  • Trusting and intimacy
  • Borderline Spectrum
  • Influences interpretation of and coping with new
    traumatic incidents

Types of Trauma
  • Delayed PTSD
  • Delayed Onset (several months)
  • Long Delayed (years)
  • Early chronic trauma influences later
    susceptibility to PTSD from a traumatic event
  • Example of childhood molestation influencing
    susceptibility to later relationship abuse
  • Case 19 y/o SWF victimized as 12 y/o by
    fathers business partner father did not take
    appropriate action but later got her
    counseling from a married 52 y/o Church of
    Scientology counselor who then started a sexual
    relationship with her, which quickly turned
    controlling with threats
  • Other cases are similar in getting involved in
    abusive relationships, which are seen as normal,
    or from which the victim cant find a way out.

Psychophysiology of Trauma
  • Imaging shows
  • Enhanced Reticular Activating System arousal
  • Enhanced Periaquiductal Grey arousal
  • Limbic Involvement
  • Acute trauma related to
  • increased limbic/hippocampal processing
  • Increased cortisol and glutamate/NMDA receptor
  • Chronic trauma related to decreased limbic
  • Possibly due to excessive cortisol and glutamate

  • Hypothalamic-Pituitary-Adrenal Axis
  • Situation interpreted as emergency
  • Classical Conditioning of paired emotion-episodic
    memory (amygdala-hippocampus)
  • Continual Reprocessing of Reaction
  • Internal recall kept active, since situation
    could recur
  • External generalizability of situation to similar
  • Frontal interpretation (serious life threatening
    problem deal with it)
  • ? Limbic Reaction (keep brain and body in
    emergency status)
  • ? Frontal Interpretation (Stay alert in case
    emergency returns!)
  • ? Limbic Reaction (keep brain and body
    in emergency status)
  • ? Etc. (focusing on the problem
    keeps the problem real)

  • According to the National Institutes of Mental
    Health, 5.2 million Americans aged 18-54 have
  • Untold millions have had traumatic experiences
    that affect their lives
  • The Veteran's Administration (VA) operates more
    than 140 specialized programs for the treatment
    of PTSD through VA Medical Centers and Clinics.
    In 2001, more than 77,300 veterans were treated
    for PTSD by VA specialists.
  • National Institute of Mental Health. Reliving
    Trauma, Post-traumatic Stress Disorder. Available
    at http//
  • Department of Veterans Affairs. Fact Sheet VA
    programs for veterans with Post-Traumatic Stress
    Disorder (PTSD). Available at http//

Predisposition to PTSD
  • Prior psychological difficulties
  • Prior traumatic event
  • Especially which was not coped with well
  • Especially which was chronic
  • Especially which involved caregivers
  • Prior psychological diagnosis
  • (especially Anxiety disorders)
  • Personality / Coping Style
  • Very reflective and sensitive (hyper-reflective
    anxious PTSD)
  • Blunted and non-reflective (angry/repressive type
  • Meaninglessness

Prevalence and Time Course
  • A prospective longitudinal study assessed 967
    consecutive patients who attended an emergency
    clinic shortly after a motor vehicle accident,
    again at 3 months, and at 1 year.
  • The prevalence of posttraumatic stress disorder
  • 23.1 at 3 months
  • 16.5 at 1 year.
  • Chronic PTSD was related to some objective
    measures of trauma severity
  • perceived threat, and dissociation during the
  • to female gender, to previous emotional problems,
    and to litigation.
  • Maintaining psychological factors enhanced the
    accuracy of the prediction
  • negative interpretation of intrusions,
    rumination, thought suppression, and anger
  • The most important predictors of PTSD symptoms at
    1 year were
  • Negative interpretation of intrusions, persistent
    medical problems, and rumination at 3 months,
  • Cases of delayed onset related to anger
    cognitions, injury severity, and prior emotional
  • Ehlers, A, Mayou, R, Bryant, B (1998)
    Psychological Predictors of Chronic Posttraumatic
    Stress Disorder After Motor Vehicle Accidents
    Journal of Abnormal Psychology 107(3) 508-519

Prevalence and Time Course
  • Gray, MJ, Bolton, EE Litz, BT (2004).
    Longitudinal Analysis of PTSD Symptom Course
    Delayed-Onset PTSD in Somalia Peacekeepers JCCP
    2004, Vol. 72, No. 5, 909913.
  • N1035 sample followed over one year
  • Sample Type PTSD Sx Score
  • Time 1 Time 2
  • 902 Resilient (few Sx) 24 25
  • 47 Acute onset, no remittance 59 57
  • Remitters (acute onset, remitted) 53 35
  • 68 Delayed Onset 34 52
  • (about 14 of sample developed significant Sx,
    about ½ was delayed onset)

Typical Treatments
  • Medications
  • For each type of PTSD
  • Cognitive Behavioral Therapies
  • For each type of PTSD
  • Rational vs automatic responses
  • Individual vs group
  • Critical Incident Stress Debriefings (CISD)
  • Immediately following a disaster to prevent PTSD

Typical Treatments Medication
  • Acute Stress D/O
  • Beta Blockade
  • Benzodiazepine
  • Acute PTSD
  • Chronic PTSD
  • SSRI
  • Anti-Psychotic
  • Benzodiazepine?
  • Sleep Support

Typical Treatments CBT for Complex PTSD
  • 121 female rape victims, most of whom had
    extensive histories of trauma, were randomly
    assigned to cognitive-processing therapy,
    prolonged exposure, or a delayed-treatment
    waiting-list condition.
  • Both types of treatment were equally effective
    for treating complex PTSD symptoms,
  • The sample was then divided into two groups
    depending upon whether they had a history of
    child sexual abuse. Both groups improved
    significantly over the course of treatment with
    regard to PTSD, depression, and the symptoms of
    complex PTSD as measured by the Trauma Symptom
    Inventory. Improvements were maintained for at
    least 9 months.
  • These findings indicate that cognitive-behavioral
    and exposure therapies are effective for patients
    with complex trauma histories and symptoms
  • Resick PA. Nishith P. Griffin MG. (2003) How
    well does cognitive-behavioral therapy treat
    symptoms of complex PTSD? An examination of child
    sexual abuse survivors within a clinical trial.
    Cns Spectrums. 8(5)340-55.

Typical Treatments
  • Critical Incident Stress Debriefing / Management
  • Makes Clinical Sense
  • Unlikely to do harm
  • Likely to be useful as screening assessment
  • Likely to be useful to normalize therapy for
  • Not good evidence of value in reducing PTSD Dx or
    Sx in studies and meta analysis, and therefore
    not as widely recommended as it once was

Experiential Therapies Dissociation
  • Relaxation
  • Physical (Autonomic) Emphasis
  • PSNS retraining
  • Muscle relaxation
  • Slow breathing
  • Biofeedback
  • Efficacy?
  • Alone has limited effects
  • More effective in combination with other

Experiential Therapies Dissociation
  • Meditation
  • Attentional retraining
  • Attention is enhanced processing
  • Whatever you attend to, you enhance
  • (worry, pain, noise, arousal / breath, warmth,
  • Your brain/body support what you attend to
  • H-P-A axis
  • (ANS activation PAG relay Limbic arousal
    frontal interpretation for SNS or PSNS)
  • If you can address a problem, then do so,
    otherwise focus on neutral or positive sensations
    or activity
  • Meditation helps reduce background noise and
    enhance foregrounded signal
  • ZEN MEDITATION (signal emphasis)
  • VIPASSANA MEDITATION (noise reduction)

Experiential Therapies Controlled Dissociation
  • Hypnosis
  • Principles
  • Controlled dissociation (x4)
  • Hypnotizability
  • Methods
  • Light trance
  • CBT relaxation graded exposure
  • Bypasses typical conscious resistance (schema)
  • Deep trance
  • Bypasses conscious resistance/habit schema
  • Reassociates new emotions with old memories
  • Efficacy?
  • Reportedly high for highly hypnotizable pts
  • Highly hypnotizable pts may do worse w/o tx,
    better w/tx

Experiential Therapies Dissociation
  • EMDR
  • Principles
  • Methods
  • Efficacy?
  • Meta analyses and comparative studies show it may
    be effective in PTSD, but is not more effective
    than other therapies
  • May be only exposure therapy with ritual

Experiential Therapies EMDR
  • The authors examined the efficacy, speed, and
    incidence of symptom worsening for 3 treatments
    of posttraumatic stress disorder (PTSD)
    prolonged exposure, relaxation training, or eye
    movement desensitization and reprocessing (EMDR)
    N 60. Treatments did not differ in attrition,
    in the incidence of symptom worsening, or in
    their effects on numbing and hyperarousalsymptoms.
  • Compared with EMDR and relaxation training,
    exposure therapy (a) produced significantly
    larger reductions in avoidance and reexperiencing
    symptoms, (b) tended to be faster at reducing
    avoidance, and (c) tended to yield a greater
    proportion of participants who no longer met
    criteria for PTSD after treatment. EMDR and
    relaxation did not differ from one another in
    speed or efficacy.
  • Taylor, S. Thordarson, D. Maxfield, L. Fedoroff,
    I. Lovell, K. Ogrodniczuk, J. (2003). Comparative
    Efficacy, Speed, and Adverse Effects of Three
    PTSD Treatments Exposure Therapy, EMDR, and
    Relaxation Training Journal of Consulting and
    Clinical Psychology 71(2) 330-338

Experiential Therapies EMDR
  • Meta Analyses Eye movement desensitization and
    reprocessing (EMDR), a controversial treatment
    suggested for posttraumatic stress disorder
    (PTSD) and other conditions, was evaluated in a
    meta-analysis of 34 studies that examined EMDR
    with a variety of populations and measures.
  • Process and outcome measures were examined
    separately, and EMDR showed an effect on both
    when compared with no treatment and with
    therapies not using exposure to anxiety-provoking
    stimuli and in pre-post EMDR comparisons.
  • However, no significant effect was found when
    EMDR was compared with other exposure techniques.
  • No incremental effect of eye movements was noted
    when EMDR was compared with the same procedure
    without them.
  • R. J. DeRubeis and P. Crits-Christoph (1998)
    noted that EMDR is a potentially effective
    treatment for noncombat PTSD, but studies that
    examined such patient groups did not give clear
    support to this.
  • In sum, EMDR appears to be no more effective than
    other exposure techniques, and evidence suggests
    that the eye movements integral to the treatment,
    and to its name, are unnecessary.
  • Davidson, P. Parker, K. (2001) Eye Movement
    Desensitization and Reprocessing (EMDR) A
    Meta-Analysis. JCCP 69(2) 305-316.

Experiential Therapies Exposure
  • In the 1980s, Terence Keane and colleagues found
    that exposure therapy was effective in treating
    the PTSD symptoms of Vietnam War veterans.
  • In the 90s, research by Edna Foa and her
    colleagues showed that exposure therapy was
    perhaps the most effective Tx for reducing PTSD
    symptoms of rape victims, including persistent
    fear. Improvements were seen immediately after
    exposure therapy, and sustained during a
    three-month follow-up.
  • Foa, E. B., Rothbaum, B. O., Riggs, D. S.,
    Murdock, T. B. (1991). The treatment of
    posttraumatic stress disorder in rape victims A
    comparison between cognitive-behavioral
    procedures and counseling. Journal of Consulting
    and Clinical Psychology, 59, 715-723.
  • Foa, E. B., Meadows, E. A. (1997). Psychosocial
    treatments for posttraumatic stress disorder A
    critical review. Annual Review of Psychology, 48,
  • Keane, T. M. Kaloupek, D. G. (1982). Imaginal
    flooding in the treatment of a posttraumatic
    stress disorder. Journal of Consulting and
    Clinical Psychology, 50, 138-140.
  • Keane, T. M., Fairbank, J. A., Caddell, J. M.,
    Zimering, R. T. (1989). Implosive (flooding)
    therapy reduced symptoms of PTSD in Vietnam
    combat veterans. Behavior Therapy, 20, 245-260

Experiential Therapies Exposure
  • Flooding
  • Sudden and total immersion into arousing
  • (not recommended for PTSD due to potential for
  • Graded Exposure
  • Gradually increasing immersion into arousing
    environment, as the patient is able to tolerate.
  • Re-associate previously traumatic cognitions with
    comfortable or neurtral affect
  • Discussion (CISD)
  • Procedure
  • Efficacy with different populations
  • Imagery
  • Using internal visual images for those with
    imagery capacity (-20)
  • Virtual Reality

VR Assisted Graded Exposure
  • VR assisted GRADED EXPOSURE with
    biofeedback/attentional retraining
  • Combining the best of high tech and low tech

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  • With Medication that soothes limbic arousal
  • Does de-arousing medication
  • Allow greater mental and physical relaxation
  • Yes
  • allow greater exposure
  • Yes
  • Prevent generalizability post treatment?
  • Doesnt seem to instead, it extends long term
    outcome at least in one small, well conducted
    study using DCS
  • (Ressler et al (Nov 2004) Cognitive Enhancers
    as Adjuncts to Psychotherapy. Arch Gen
    Psychiatry, 61 1136-1144)

Meta Analyses
  • Van Etten and Taylor analyzed 61 treatment trials
    that included pharmacotherapy and modalities such
    as behavior therapy (particularly exposure
    therapy), eye movement desensitization and
    reprocessing (EMDR), relaxation training,
    hypnotherapy, and dynamic psychotherapy. Overall,
    this meta-analysis found that exposure therapy
    was more efficacious than any other type of
    treatment for PTSD when measured by clinician
    rated measures.
  • Specifically, the effect size for all types of
    psychotherapy interventions was 1.17 compared
    with 0.69 for medication. Perhaps more
    significant, the mean dropout rate in medication
    trials was 32 compared with 14 in psychotherapy
  • A second meta-analysis of psychotherapeutic
    treatments found that treatment benefits for
    target symptoms of PTSD and for general
    psychological symptoms (intrusion, avoidance,
    hyperarousal, anxiety, and depression) were
    significant, with effect sizes ranging from 0.2
    to 0.49
  • Van Etten ML, Taylor S. Comparative efficacy of
    treatments for posttraumatic stress disorder A
    meta-analysis. Clinical Psychology and
    Psychotherapy 1998514454.
  • Sherman JJ. Effects of psychotherapeutic
    treatments for PTSD. J Trauma Stress

Consensus Panel on PTSD
  • Ballenger JC. Davidson JR. Lecrubier Y. Nutt DJ.
    Foa EB. Kessler RC. McFarlane AC. Shalev AY.
  • Title Consensus statement on posttraumatic
    stress disorder from the International Consensus
    Group on Depression and Anxiety.
  • Source Journal of Clinical Psychiatry. 61 Suppl
    560-6, 2000.
  • EVIDENCE The consensus statement is based on the
    6 review articles that are published in this
    supplement and the scientific literature relevant
    to the issues reviewed in these articles.
  • CONCLUSION Selective serotonin reuptake
    inhibitors are generally the most appropriate
    choice of first-line medication for PTSD, and
    effective therapy should be continued for 12
    months or longer. The most appropriate
    psychotherapy is exposure therapy, and it should
    be continued for 6 months, with follow-up therapy
    as needed.

  • SSRI Sleep support along with Experiential
    Therapies which focus on development of cognitive
    and somatic skills are very beneficial in the
    treatment of simple acute PTSD.
  • SSRI along with Cognitive and Interpersonal
    Therapies in combination with Experiential
    Therapies may be necessary in the treatment of
    complex chronic PTSD.

Adapting for Counseling Centers
  • Assess
  • simple acute vs chronic complex
  • existing coping skills vs need for medication
    support (sleep, unable to engage in or benefit
    from therapy)
  • willingness to develop personal skills to improve
    vs needing continued external interpersonal
    support and understanding

Adapting for Counseling Centers
  • Provide a cognitive frame
  • Psychoeducation for how trauma symptoms occur
  • Normalize
  • Explain the psychophysiology
  • Explain the Sx
  • Cognitive Therapy for understanding
  • Habit stimuli, cog/emot/physiol/behavioral
  • Optimal / healthy reactions
  • Skills needed to obtain these optimal reactions

Adapting for Counseling Centers
  • Offer interpersonal support if need be
  • Group process (but be careful not to develop a
    sick role attitude
  • Time limited
  • CBT oriented with interpersonal discussion
  • Family/couple therapy

Adapting for Counseling Centers
  • If complex/chronic
  • Address current crisis
  • Consider dynamic approach
  • Discuss early childhood traumas
  • How these influence current
  • Personality and Beliefs about self, others, world
  • Interpretations of and reactions to past critical
    and current events
  • Discuss optimal / normal interpretations

Adapting for Counseling Centers
  • Introduce Experiential Methods
  • 1st develop skills of being comfortably in the
  • 2nd take a mildly uncomfortable event and
    practiced with it
  • Tolerate sustaining attention to it
  • Distance as necessary to sustain attention to it
  • Return to being comfortably in the moment
  • Go back and forth several times to teach basic
  • (optimally with biofeedback monitoring
    otherwise minimal cues and verbal SUDS)

Adapting for Counseling Centers
  • Experiential Methods
  • 3rd Take more relevant but moderately arousing
    event, and repeat step 2 above
  • 4th Take most relevant and arousing event, and
    repeat step 2 above
  • Continue until no major arousal occurs
  • Note Each step could take several sessions
  • This can be done in group as well (but
  • warnings not to use very arousing
    stimuli at first)

Adapting for Counseling Centers
  • Typical Session
  • Review Sx since last session
  • Review practice since last session
  • Practice meditation (attentional retraining)
  • If successful, introduce moderate stressor
  • Arousal, distance as necessary
  • Return to meditation (alternate every few
  • If successful, introduce stronger stressor
  • Arousal, distance as necessary
  • Return to meditation (alternate, every few
  • Debrief and discuss practice times and situations

Adapting for Counseling Centers
  • Practice
  • In group
  • With partners

Adapting for Counseling Centers
  • Discuss issues related to implementation in
    counseling center context
  • Settings/sessions
  • Non-specialized staff therapists
  • Difficult students
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