This presentation explains the background to the current definition of PTSD as it still stands in 2011 and the NICE guideline current treatment recommendations. It then considers some controversy in the field amongst the researchers regarding the lack of effect differences between different treatments and finishes with pragmatic suggestions about future direction.
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Ptsd resolution5.2
1. PTSD research and statistics
Bill Andrews
Pragmatic Research Network
Sunday, 6 February 2011 1
2. PTSD treatment: the facts;
outcomes of therapy
Bill Andrews
Pragmatic Research Network
Sunday, 6 February 2011 1
3. Bill Andrews
Research Coordinator
Pragmatic Research Network
Sunday, 6 February 2011 2
The HGIPRN is expanding now to inclue and encourage a wider audience. The HGIPRN will
forma sub-set of the total number of data contributors.
4. Bill Andrews
Senior advisor
ICCE
www.centerforclinicalexcellence.com
Sunday, 6 February 2011 3
The ICCE is a great resource.
5. What is PTSD? 1/6
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 4
6. 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, 2000
Sunday, 6 February 2011 4
7. What is PTSD? 2/6
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 5
8. 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, 2000
Sunday, 6 February 2011 5
9. What is PTSD? 3/6
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 6
10. What is PTSD? 3/6
• C: Persistent avoidance of stimuli
associated with the event(s)
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 6
11. What is PTSD? 4/6
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 7
12. What is PTSD? 4/6
• D: Elevated arousal that was NOT present
prior to the event(s)
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 7
13. What is PTSD? 5/6
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 8
14. What is PTSD? 5/6
• E: The symptoms must persist for more
than 1 month
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 8
15. What is PTSD? 6/6
DSM-IV-TR, APA, 2000
Sunday, 6 February 2011 9
16. 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, 2000
Sunday, 6 February 2011 9
28. PTSD research and statistics
Sunday, 6 February 2011 13
29. PTSD research and statistics
• Evidence hierarchy
Sunday, 6 February 2011 13
30. PTSD research and statistics
• Evidence hierarchy
• RCT
Sunday, 6 February 2011 13
31. PTSD research and statistics
• Evidence hierarchy
• RCT
• Meta-analysis of RCT studies
Sunday, 6 February 2011 13
32. Meta-Analysis of Risk Factors for
PTSD in Trauma-Exposed Adults
Sunday, 6 February 2011 14
33. 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
34. 2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.
Sunday, 6 February 2011 15
Lack of social support is the greatest predictor of the risk of developing PTSD.
35. 2000. Brewin, Andrews & Valentine. Journal of Consulting and Clinical Psychology. 68. 5.
Sunday, 6 February 2011 15
Lack of social support is the greatest predictor of the risk of developing PTSD.
46. 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, 2006
Sunday, 6 February 2011 19
47. Meta-analysis of PTSD treatments
Sunday, 6 February 2011 20
Agreement of no difference between trauma focused treatments.
48. Meta-analysis of PTSD treatments
• Common focus on the patient’s traumatic
memories of the traumatic event &
personal meaning of the trauma
Sunday, 6 February 2011 20
Agreement of no difference between trauma focused treatments.
49. 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 treatments
Sunday, 6 February 2011 20
Agreement of no difference between trauma focused treatments.
50. Meta-analysis of PTSD treatments
Sunday, 6 February 2011 21
Controversy over finding that in fact there is no difference between ANY studied treatments
that are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding
51. Meta-analysis of PTSD treatments
• Benish et al, 2008
Sunday, 6 February 2011 21
Controversy over finding that in fact there is no difference between ANY studied treatments
that are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding
52. Meta-analysis of PTSD treatments
• Benish et al, 2008
• NO DIFFERENCE in OUTCOMES
between ANY bona fide treatments,
WHETHER TRAUMA FOCUSED OR NOT
Sunday, 6 February 2011 21
Controversy over finding that in fact there is no difference between ANY studied treatments
that are ‘bona-fide’. This has been hotly debated and all the intense criticism of the finding
53. TM
c Bill Andrews 2010
Sunday, 6 February 2011 22
Let’s be pragmatic.
56. Pragmatic Research Network
TM
c Bill Andrews 2010
pragmaticresearchnetwork.blogspot.com
Sunday, 6 February 2011 24
The main purpose of a network is to try to investigate what is going on in practice.
57. Ask the Customers (n = 130)
Sunday, 6 February 2011 25
The data speaks for itself.
58. Ask the Customers (n = 130)
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Sunday, 6 February 2011 25
The data speaks for itself.
59. Ask the Customers (n = 130)
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Sunday, 6 February 2011 25
The data speaks for itself.
60. Ask the Customers (n = 130)
!"#$%&'( !"#$%&'(
&'()-+./0" &'()-+./0"
1234*$!" 1234*56"
&'()*+,'" &'()*+,'"
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!"#$
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!" #!" $!!" $#!" %!!" %#!" &!!" &#!"
Sunday, 6 February 2011 25
The data speaks for itself.
63. Ask the Customers (n = 130)
!"!#$%&'(!%
()*+,01$
)*/$
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Sunday, 6 February 2011 26
The effect sizes are large.
64. Ask the Customers (n = 130)
!"!#$%&'(!%
()*+,01$
)*/$
23245$6782$
.+/,+$
()*+,!-$
!"#$ !"%$ !"&$ '$ '"!$ '"'$
Sunday, 6 February 2011 26
The effect sizes are large.
65. Ask the very distressed (n = 44)
Sunday, 6 February 2011 27
Clients seem to be moving to below the cut-off, even when the more distressed cohort are
looked at.
66. Ask the very distressed (n = 44)
IES-E
+,-.,/$"
0123456"47"89"1":"&&"
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!" #!" $!" %!" &!" '!" (!" )!" *!"
Sunday, 6 February 2011 27
Clients seem to be moving to below the cut-off, even when the more distressed cohort are
looked at.
67. Ask the very distressed (n = 44)
CORE-34 IES-E
'()*+&,"-%" +,-.,/$"
./01234"25"67"/"8",,"
0123456"47"89"1":"&&"
'()*+&,"-$" +,-.,/#"
!" #" $!" $#" %!" %#" &!" !" #!" $!" %!" &!" '!" (!" )!" *!"
Sunday, 6 February 2011 27
Clients seem to be moving to below the cut-off, even when the more distressed cohort are
looked at.
68. Ask the very distressed (n = 44)
CORE-34 IES-E
'()*+&,"-%" +,-.,/$"
./01234"25"67"/"8",,"
0123456"47"89"1":"&&"
'()*+&,"-$" +,-.,/#"
!" #" $!" $#" %!" %#" &!" !" #!" $!" %!" &!" '!" (!" )!" *!"
Sunday, 6 February 2011 27
Clients seem to be moving to below the cut-off, even when the more distressed cohort are
looked at.
69. Ask the very distressed
Sunday, 6 February 2011 28
The data compares very favourably with one of the studies into PTSD from Northern Ireland.
70. Ask the very distressed
Duffy et al n = 47
bdi conversion
'()*+&,"-%"
'./01"23"/."4"5",6"
'()*+&,"-$"
!" #" $!" $#" %!" %#" &!"
Sunday, 6 February 2011 28
The data compares very favourably with one of the studies into PTSD from Northern Ireland.
71. Ask the very distressed
Duffy et al n = 47 Andrews et al n = 44
bdi conversion CORE-34
'()*+&,"-%" '()*+&,"-%"
./01234"25"67"/"8",,"
'./01"23"/."4"5",6"
'()*+&,"-$" '()*+&,"-$"
!" #" $!" $#" %!" %#" &!" !" #" $!" $#" %!" %#" &!"
Sunday, 6 February 2011 28
The data compares very favourably with one of the studies into PTSD from Northern Ireland.
72. Ask the very distressed
Duffy et al n = 47 Andrews et al n = 44
bdi conversion CORE-34
'()*+&,"-%" '()*+&,"-%"
./01234"25"67"/"8",,"
'./01"23"/."4"5",6"
'()*+&,"-$" '()*+&,"-$"
!" #" $!" $#" %!" %#" &!" !" #" $!" $#" %!" %#" &!"
Sunday, 6 February 2011 28
The data compares very favourably with one of the studies into PTSD from Northern Ireland.
73. Predictors of PTSD
• lack of social support
• post-trauma life stress
• trauma severity
Sunday, 6 February 2011 29
75. Likely Predictors of
PTSD Resolution
• recognising the importance of social support
Sunday, 6 February 2011 30
76. Likely Predictors of
PTSD Resolution
• recognising the importance of social support
• teaching skills for management of post-trauma
life stress
Sunday, 6 February 2011 30
77. 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
Sunday, 6 February 2011 30
78. 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 treatment
Sunday, 6 February 2011 30
80. Meta-analysis of PTSD treatments
• NO DIFFERENCE between ANY of these
trauma-focused treatments
Sunday, 6 February 2011 31
81. 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 NOT
Sunday, 6 February 2011 31
83. Where Scientists Agree
Possible Factors important to successful treatments of PTSD
Sunday, 6 February 2011 32
84. Where Scientists Agree
Possible Factors important to successful treatments of PTSD
• Therapists...ask yourself how many of these you can
tick off
Sunday, 6 February 2011 32
85. 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 treatment
Sunday, 6 February 2011 32
87. Possible Factors important to
successful treatments of PTSD
• Cogent rationale that is acceptable to patient
Sunday, 6 February 2011 33
88. Possible Factors important to
successful treatments of PTSD
• Cogent rationale that is acceptable to patient
• Set of treatment actions consistent with the rationale
Sunday, 6 February 2011 33
89. 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
Sunday, 6 February 2011 33
90. 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
Sunday, 6 February 2011 33
91. 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
Sunday, 6 February 2011 33
92. 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 resilience
Sunday, 6 February 2011 33
94. Possible Factors important to
successful treatments of PTSD
• Education about PTSD
Sunday, 6 February 2011 34
95. Possible Factors important to
successful treatments of PTSD
• Education about PTSD
• Opportunity to talk about trauma if desired
Sunday, 6 February 2011 34
96. Possible Factors important to
successful treatments of PTSD
• Education about PTSD
• Opportunity to talk about trauma if desired
• Ensuring the patient's safety, especially if the patient has
been vicitimized (domestic violence, neighborhood
violence, or abuse)
Sunday, 6 February 2011 34
97. Possible Factors important to
successful treatments of PTSD
• Education about PTSD
• Opportunity to talk about trauma if desired
• Ensuring the patient's safety, especially if the patient has
been vicitimized (domestic violence, neighborhood
violence, or abuse)
• Helping patients learn how to avoid re-victimization
Sunday, 6 February 2011 34
98. Possible Factors important to
successful treatments of PTSD
• Education about PTSD
• Opportunity to talk about trauma if desired
• Ensuring the patient's 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 efficacy
Sunday, 6 February 2011 34
99. Pragmatic Approach
Sunday, 6 February 2011 35
The Pragmatic Approach tries to find a middle ground between the different sides of the
argument.
100. 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 York
Sunday, 6 February 2011 35
The Pragmatic Approach tries to find a middle ground between the different sides of the
argument.
102. Pragmatic Research Implications for
Innovative Psychological Trauma Treatments
• Put the feedback of the service user at the top of the agenda
Sunday, 6 February 2011 36
103. 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
Sunday, 6 February 2011 36
104. 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
Sunday, 6 February 2011 36
105. 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
Sunday, 6 February 2011 36
106. 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
Sunday, 6 February 2011 36
107. 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 control
Sunday, 6 February 2011 36
108. Steve Hollon
“ with respect to randomization I would paraphrase
Churchill on democracy, that it is a terrible process
that has little to recommend it except that it is better
than the alternatives”
(Hollon, S. 2009)
Sunday, 6 February 2011 37
109. 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 38
Paul suggests we need to move away from this evidence hierarchy.
110. 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
111. Prof. Gordon Turnbull
Frontiers in Trauma Treatment
BILL: What in your opinion are the
significant breakthroughs in
Trauma Treatment?
Sunday, 6 February 2011 40
113. The New Frontier
• unprocessed trauma memories control and cause
exaggerated function of the ANS
Sunday, 6 February 2011 41
114. The New Frontier
• unprocessed trauma memories control and cause
exaggerated function of the ANS
• PTSD is truly a MIND/BODY experience
Sunday, 6 February 2011 41
115. 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
Sunday, 6 February 2011 41
116. 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
Sunday, 6 February 2011 41
117. 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
Sunday, 6 February 2011 41
118. 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
Sunday, 6 February 2011 41
119. 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
• Acupressure
Sunday, 6 February 2011 41
123. The New Frontier
• Using a treatment that
works on soothing the
ANS and works on the
right hemisphere is likely
to be a good idea
Sunday, 6 February 2011 43
125. Medications
• Propranolol (lowering adrenaline)
useful in the Acute Stress Reaction
phase to reduce the ‘etching’ of the
emotionally charged memories
Sunday, 6 February 2011 44
126. 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 flooding
Sunday, 6 February 2011 44
128. 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
Sunday, 6 February 2011 45
129. 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
Sunday, 6 February 2011 45
130. 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
132. Bill’s take home message
• have a healthy sense of curiosity
Sunday, 6 February 2011 46
133. Bill’s take home message
• have a healthy sense of curiosity
• keep an open mind
Sunday, 6 February 2011 46
134. Bill’s take home message
• have a healthy sense of curiosity
• keep an open mind
• systematically reflect on your work
Sunday, 6 February 2011 46
135. 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 research
Sunday, 6 February 2011 46
138. Bill’s take home message
• measure your outcomes
Sunday, 6 February 2011 47
139. Bill’s take home message
• measure your outcomes
• support research and/or get involved
in case study research yourself
Sunday, 6 February 2011 47
140. Bill’s take home message
• measure your outcomes
• support research and/or get involved
in case study research yourself
• be respectful of other modalities
Sunday, 6 February 2011 47
141. 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 clients
Sunday, 6 February 2011 47