Tag: PTSD

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BABCP Response - NICE Consultation January 2022

Terrorfied By Bomb Attacks

Victims of terrorists attack may suffer from post-traumatic stress disorder, living in terror of a further attack. Treatment needs to change to help victims deal with their state of ‘terrified surprise’ [ Scott (In submission) PTSD – An Alternative Paradigm and Scott (2013) CBT for Common Trauma Responses London; Sage Publications]. Clients should be encouraged to swap the glasses gifted by the extreme trauma and through which today is seen as a ‘war zone’, for the glasses they wore the day before the trauma. Below is a handout to help terrorist attack victims gauge the actual personal threat level:

If you have been the victim of a terrorist attack and have PTSD as a consequence, you likely feel ‘there could be another attack anytime’. Life is spent avoiding anywhere remotely like the scene of the attack.  You probably also take flight at the sight of anyone or any object that reminds you of the attack.  Life is lived in a state of ‘terrified surprise’, jumping out of your skin at unexpected noises or sudden movements, perhaps getting angry when this happens. You repeatedly check for signs of danger, seek to minimise risk by for example keeping the exit in sight in enclosed spaces. This all comes to feel normal and that the only safe place is home, but home has actually become a ‘bunker’ and you get cross with others not staying in a ‘bunker’, relationships become strained and there’s an increasing sense of isolation.

  Numbers Murdered In Attack   Odds of Being Killed 1 in…   Numbers Injured  Odds   of being injured 1 in….
2016   97.3 million     19   3.5 million
2017     37   1.8 million   300   220,000
2018    0   infinite   3   23 million

The above odds should be contrasted with the far greater odds of being killed in a car crash at some point in your life, of 1 in 103  or as a pedestrian 1 in 556.

The chances of exposure to an extreme trauma at a public gathering are about 1 in 11,000. [ 6000 had people brought tickets for the Manchester Arena Concert in which 22 people died as a result of the bombing]. Would you bet on a horse in the Grand National at these sort of odds?

The real risk of danger from a terrorist attack is nothing like the PTSD sufferer imagines, the vividness of the memory sounds, smells, feelings of helplessness give a very distorted impression of the likelihood of being a victim. Life is then about daring to live as if you are not in this ‘hall of mirrors’/ ‘war zone’.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

‘Optimal Outcomes Are Not Being Obtained Using Current Gold-Standard , Trauma Focused Interventions…..’

according to a recent editorial in the American Journal of Psychiatry, by Dr Robin L Aupperie, he continues ‘evidence is mounting that non trauma focused therapies may have at least equal efficacy for the treatment of PTSD’. See the link below:

https://www.dropbox.com/s/aexz30a6t04apen/PTSD%20%20trauma%20focussed%20CBT%20dogma%202018.pdf?dl=0

he points to only 30-40% of veterans with PTSD losing their diagnostic status following trauma focussed cbt. Dr Aupepperie raises doubts about ‘the presumed essentiality of trauma processing for the effective treatment of PTSD’. I have also raised doubts about it in a paper ‘PTSD an Alternative Paradigm’ which is under submission.

But there is a need to tread carefully in that there needs to be replication studies of the non-trauma focussed interventions in real world settings i.e not just with patients volunteering for a treatment, and across a broad range of settings i.e civilian and military. Nevertheless it does raise an eyebrow when a study comparing 8 individual sessions of mantram therapy with 8 individual sessions of present centred therapy [ Borman et al (2018) Am J Psychiatry, 175:979-988] concluded that 59% of the former no longer met criteria for PTSD at 2 month follow up compared to 40% in the latter. However psychology in general is replete with studies that have not been replicated [ Chris Chambers The 7 Deadly Sins of Psychology (2017) ‘After spending fifteen years in psychology and its cousin, cognitive neuroscience, I have nevertheless reached an unsettling conclusion. If we continue as we are then psychology will diminish as a reputable science and could very well disappear’] because positive outcomes are more likely to be published [ the file drawer problem] and the originators of a theory/intervention tend to be very charasmatic, creating a placebo effect. I have a feeling that the replication crisis is not taken as seriously in clinical work, with a paucity of studies in real world settings, using ordinary therapists and employing gold-standard assessments.

Just a footnote: the mantram therapy involved the repetition of a spiritually meaningful word, initially in non stressful situations e.g before bed, then applying this flashbacks and when woken from nightmares. The idea is to slow down thoughts and induce relaxation. The present centred therapy discusses current stresses and the problem solving of them in a non formal way. But in neither intervention was there a trauma focus.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

CBT for PTSD and Beyond Workshop October 4th 2018

Here is the Powerpoint Preserntation:

 

https://www.dropbox.com/s/gno26s2dsubd9oa/CBT%20for%20PTSD%20and%20Beyond%20Workshop%20October%204th%202018.pptx?dl=0

 

Do get back to me any questions

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Who Arrested Information Processing?

Was it Freud, Horowitz, Foa, Resick, Shapiro, Brewin or Ehlers? Arrested information processing has long been held as pivotal in the development of PTSD, but in my Workshop, ‘CBT for PTSD and Beyond’ to be delivered at the Lakeside Centre, Crosby, Liverpool on October 4th 2018 under the auspices of Merseyside BABCP I question this.

 

There is also a paper ‘PTSD An Alternative Paradigm’ in submission.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Rules of Thumb That Can Sabotage The Treatment of PTSD

In routine practice the treatment of PTSD is often ineffective, IAPT’s recovery rate with this disorder is around 16%. But the operation of certain rules of thumb sabotage treatment across the board. Which, if any,  of the following saboteurs do you operate on:

  1. It is probably PTSD because it was an awful incident
  2. It is probably PTSD because there arte flashbacks and nightmares
  3. It is probably PTSD because of a high score on the Impact of Event Scale
  4. Whatever it actually is trauma focused CBT/EMDR offers the best way of resolving it
  5. Formulation rules anyway
  6. You can’t treat more than one disorder at a time
  7. Issues need to be resolved first

 

In January 2018 I was due to make a presentation at an Improving Access to Psychological Therapies (IAPT) Conference, titled ‘Approaching Patients With Trauma – Can IAPT help patients with trauma?, but was overtaken by my own trauma of falling down the stairs at home! Here is the link to the presentation:

https://www.dropbox.com/s/21ye8ewczvmfamn/IAPT-January-23rd-2018-Birmingham-City-Football-Ground.pdf?dl=0

The good news is that I was able to specify how IAPT might change its’ practice, but unfortunately the chances of this happening anytime soon are remote, openness to debate with those outside of IAPT is conspicuous by its’ abscence.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

PTSD and Winnie-the-Pooh

Winnie-the-Pooh’s 100 Acre Wood has taken on a whole new meaning, after watching on DVD ‘Goodbye Christopher Robin’. The ‘Wood’ is arguably A.A Milne’s construction of a new personal world for his son (Christopher Robin), an alternative to the war zone map he appears to have operated on  since  his involvement in the Battle of the Somme in 2016, his illustrator had been involved in the Battle of Paschendale in 2017. The DVD  sees the playwright A.A Milne returning to London after his war experiences, needing to retreat to the country, startled and debilitated by unexpected noises, unhappy to make people just laugh dismayed at his son going off to another war.

 

It seems that the quest post-trauma is to seek a better map, oftentimes returning to the pre-trauma map but perhaps sometimes creating an altogether better map. Perhaps some clients are a little like Eye-ore because of their experiences!

 

Dr Mike Scott

 

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BABCP Response - NICE Consultation January 2022

Rules of Thumb That Sabotage Treatment Post Trauma

IAPT January 23rd 2018 Birmingham City Football Ground Were you thinking this heading referred to post-traumatic stress disorder (PTSD) teatment? If you did, you may have been using a particular rule of thumb relating to an exalted status for PTSD. The following may be a common set of saboteurs:

  1. It is probably PTSD because it was an awful incident
  2. It is probably PTSD because there are flashbacks and nightmares
  3. It is probably PTSD because of a high score on the IES
  4. It is probably mixed anxiety and depression because of high scores on PHQ9 and GAD7
  5. Whatever it actually is trauma focussed CBT/EMDR offers the best bet for resolving it
  6. Formulation rules anyway
  7. You can’t treat more than one disorder at a time
  8. Issues need to be resolved first

I was due to present these Saboteurs next Tuesday during an IAPT Workshop at Birmingham City Football Ground, unfortunately 2 days after Christmas I fell down the stairs, presentation of the saboteurs has been sabotaged! The Power Point Presentation is available above.  The effects of the rules of thumb are I believe devastating leading to a recovery rate of 10% in IAPT.

my paper IAPT- The Need For Radical Reform will appear in the Journal of Health Psychology shortly.

Dr Mike Scott

 

 

 

 

 

 

 

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BABCP Response - NICE Consultation January 2022

Post Trauma Mapping – circumventing difficulties with trauma focussed cbt

From an evolutionary perspective the problem with PTSD is not so much the traumatic memory but that the latter furnishes a maladaptive map, as if the sufferer is operating in a ‘war zone’.  This suggests a different treatment focus to the often resisted trauma focussed CBT.  The goal of treatment is to construct an adaptive map, this involves ‘scouting’ to ascertain where if anywhere the ‘real and present dangers’ are.  PTSD sufferers are often operating like Tony Blair on the ‘dodgy dossier’, if the weapons of mass destruction are not found in one place there is a rush to somewhere else thinking ‘they must be here’.

For clients resistant to trauma focussed CBT (TFCBT), post trauma mapping readily enhances the therapeutic alliance. Alliance problems are a bigger problem in delivering trauma focussed cbt in routine practice than have ever been acknowledged in randomised controlled trials, resulting in therapists feeling deskilled. Steve Stradling and I found that in routine practice only just over half of clients comply, even loosely defined, with a trauma focussed CBT [ Journal of Traumatic Stress (1997)].  There is a gap between what the scientist practitioners in the randomised controlled trials find and what the routine clinician/ ‘engineer’ finds in routine practice. Such mapping can be insufficient to resolve the PTSD but in passing the person becomes so acquainted with talking about the trauma that shifting from the ‘shallow end’ to exercising in the ‘deep end’, trauma focussed CBT is seemless.

From an evolutionary perspective the only function of memory is to to help us better anticipate future events, there is no value in memory per se. It may transpire that trauma focussed CBT is not actually essential for recovery from PTSD, certainly we do know that TFCBT is not necessary and is often experienced as ‘toxic’ for those traumatised but not suffering from PTSD e.g simple phobia, depression. Making it very important to carefully delineate the psychological sequelae of trauma.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022 Resources

A Screen for Mental Health – The First Step Questionnaire Revised

Clients often do not improve, not because of a lack of therapeutic skill, but because of something else  going on that they never thought to ask about. Screening clients for all common disorders is a protection against missing an important therapeutic target. The First Step Questionnaire published in Towards a Mental Health System that Works Scott (2017) London: Routledge, is such a screen, covering all the common disorders and importantly asking clients whether or not they want help with a particular difficulty, but also with a ‘don’t know’ option, so that ambivalence can be recognised from the outset. There is also an interview version the 7 Minute Interview. [ The validity studies on the Questionnaire/Interview are considered  in the Simply Effective trilogy Scott (2009), (2011) and (2013).]  I have now revised the Questionnaire/ Interview to take into account the changed diagnostic criteria for PTSD in DSM-5 and added a screen for borderline personality disorder (BPD)

The symptom questions of the PTSD screen are from the Primary Care PTSD Checklist for DSM-5,   from the US National Centre for PTSD, a positive response to 3 or more symptom questions is a positive screen for PTSD.  The  BPD screen is based on a paper by Zimmerman et al (2017) Clinically useful screen for borderline personality disorder in psychiatric outpatients, British Journal of Psychiatry, 210, 165-166. Of those with BPD over 90% endosed the affective instability question in item 11 below, but only 38% of those with affective instability had BPD i.e most of those with affective instability don’t have BPD. This illustrates that screening questions are only ever a starting point, if you don’t ask further clarifying questions in terms of the full DSM-5 criteria they can be very misleading. [Adding the anger item, see item 11 to the BPD screen meant that 97% of those with BPD answered ‘yes’ two both symptom questions according to Zimmerman et al (2017)].  It remains to be seen how much the question about wanting help adds to diagnostic accuracy, it is known that it does so for the depression screen.

 

Name:                                                                                      Date:

 

D.o.b:

 

The First Step Questionnaire – Revised

This questionnaire is a first step in identifying what you might be suffering from and pointing you in the right direction. In answering each question just make your best guess; don’t think about your response too much, there are no right or wrong answers.

 

1. Yes No Don’t know
During the past month have you often been bothered by feeling, depressed or hopeless?
During the past month have you often been bothered by little interest or pleasure in doing things?
Is this something with which you would like help?

 

 

2. Yes No Don’t know
Do you have unexpected panic attacks, a sudden rush of intense fear or anxiety?
Do you avoid situations in which the panic attacks might occur?
Is this something with which you would like help?

 

 

3.

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you
Yes No Don’t know
i. Have had nightmares about it or thought about it when you did not want to?
ii. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
iii. Were constantly on guard, watchful, or easily startled?
iv. Felt numb or detached from others, activities, or your surroundings?
v.  Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
Is this something with which you would like help?

 

4. Yes No Don’t know
Are you a worrier?
Do you worry about everything?
Has the worrying been excessive (more days than not) or uncontrollable in the last 6 months?
Is this something with which you would like help?

 

 

5. Yes No Don’t know
When you are or might be in the spotlight say in a group of people or eating/writing in front of others do you immediately get anxious or nervous
Do you avoid social situations out of a fear of embarrassing or humiliating yourself?
Is this something with which you would like help?

 

 

6. Obsessive Compulsive Disorder Yes No Don’t know
Do you wash or clean a lot?
Do you check things a lot
Is there any thought that keeps bothering you that you would like to get rid of but can’t?
Do your daily activities take a long time to finish?
Are you concerned about orderliness or symmetry?
Is this something with which you would like help?

 

7. Yes No Don’t know
Do you go on binges were you eat very large amounts of food in a short period?
Do you do anything special, such as vomitting, go on a strict diet to prevent gaining weight from the binge?
Is this something with which you would like help?

 

 

8. Yes No Don’t know
Have you felt you should cut down on your alcohol/drug?
Have people got annoyed with you about your drinking/drug taking?
Have you felt guilty about your drinking/drug use?
Do you drink/use drugs before midday?
Is this something with which you would like help?

 

9. Yes No Don’t know
Do you ever hear things other people don’t hear, or see things they don’t see?
Do you ever feel like someone is spying on you or plotting to hurt you?
Do you have any ideas that you don’t like to talk about because you are afraid other people will think you are crazy?
Is this something with which you would like help?

 

 

10. Yes No Don’t know
Have there been times, lasting at least a few days when you were unusually high, talking a lot, sleeping little?
Did others notice that there was something different about you?

If you answered ‘yes’, what did they say?

 
Is this something with which you would like help?

 

11. Yes No Don’t know
Do you have a lot of sudden changes of mood, usually lasting for no more than a few hours?
Do you often have temper outbursts or get so angry you lose control?
Is this something with which you would like help?

 

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Current Psychological Therapy Issues

Grenfell Tower Fire and IAPT Trauma Services

In The Wake of the Grenfell Tower Fire, Mrs May Has Announced Additional Monies for Mental Health Services – BBC News 10.0pm June 18th 2017.

But the devil will be in the detail, what ‘treatment’ will be funded for which victim?, delivered by whom? when?.  The UK track record on treating trauma victims is not good. I independently reviewed 65 cases of trauma victims who had gone through the Government funded Improving Access to Psychological Therapies (IAPT) Service [Scott (2017] and found overall a 15% recovery rate, one half the sample had PTSD and again the recovery rate was 15%. There was no difference in recovery rates between those treated before and those treated after a personal injury.    But the difficulties are not confined to IAPT, recently I saw a victim of the 1989 Hillsborough Football Disaster who had since shortly afterwards been attending a weekly support group for victims, run by a Charity, though grateful for its ministrations, he had never been offered evidence based psychological treatment and continued to suffer from severe PTSD, with his marriage in tatters.

The breathtaking hospitality shown to victims of the Fire by the general public, has contrasted sharply with the acknowledged dilatoriness of the Governmental response. If that hospitality is reflected in the behaviour of friends and family towards the victim this will be an enormous benefit as perceived social support is the biggest single predictor of recovery from PTSD [ see Scott (2013)] and as a consequence I have advocated inclusion of partners in treatment if appropriate. Partners and clients can both benefit from my self-help book Moving on After Trauma [Scott (2008)].

One of the biggest roadblocks to delivering Trauma Focussed CBT (TFCBT), is that therapists or clients curtail treatment because the latter cannot face repeatedly going over the details of the trauma. Yet TFCBT is effective if clients can stomach it. I have suggested that a way around this is to teach coping skills for managing the memories, even if this proves insufficient to manage the intrusions, it can become a stepping stone towards a preparedness to engage in TCBT [Scott (2013)]. In a paper currently under review with Behavioural and Cognitive Psychotherapy, titled ‘PTSD Re-imagined’, I have presented a new reconceptualization of PTSD that is user friendly and goes beyond existing forms of treatment.

Dr Mike Scott

References

Scott, M.J (2017) Towards a Mental Health System that Works London: Routledge

Scott, M.J (2013) CBT for Common Trauma Responses London: Sage Publications

Scott, M.J (2008) Moving On After Trauma London: Routledge

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