Smucker, Mervin, Borge, Finn-M., Nore, Gro, & Langkaas, Tomas. When Change is not on Time – Troubleshooting Protocol-Based Treatment of PTSD. Symposium presented at the 37th Annual Congress of the European Association for Behavioural & Cognitive Therapies, Helsinki, Finland.
Recurring and distressing thoughts and images of a traumatic event are key characteristics of posttraumatic stress disorder (PTSD). The disorder leads to significant distress and loss of functioning for those who suffer from it. Developing effective treatment for PTSD has received increased interest in the CBT field in recent years, and several protocol-based CBT approaches now exist. However, employing a treatment protocol on a specific case does not always lead to the desired change and expected progress, and a significant proportion of PTSD clients in naturalistic settings fail to respond to our CBT treatments. The central theme for this symposium is “How to progress with protocol-based PTSD treatment when change does not happen as expected?”
The speakers of this symposium present case examples undergoing different protocol-based PTSD treatments that failed to progress as expected. Various attempts to troubleshoot these cases are discussed.
From an information-processing perspective, PTSD results from inadequate emotional processing of traumatic events, and PTSD will abate once adequate or successful emotional processing has occurred. As such, it is one’s response to trauma – and not the traumatic events themselves – that produces a PTSD syndrome.
Successful emotional processing is generally thought to have occurred when the trauma victim is able to talk about, see, listen to or be reminded of the traumatic events without experiencing distress. However, many trauma victims use denial, numbing, amnesia, or other dissociative strategies as protection from information overload and the emotional distress associated with their trauma. While the use of such avoidance responses may have been adaptive survival responses at the time of the traumatic events, and perhaps for a period of time thereafter, their continued, long-term post-trauma use is often a maladaptive avoidance strategy that thwarts or delays successful emotion processing.
In Imagery Rescripting, four conditions are essential for successful emotional processing of traumatic material to occur: (1) visual and verbal activation of the trauma-related memory, including cognitive, affective, and primary sensory stimuli (visual, auditory, kinesthetic, tactile), (2) transformation of the traumatic imagery into coping/mastery imagery, (3) development of self-calming, self-soothing imagery, and (4) linguistic processing of the transformed imagery and its meaning.
In a neuroscience research study conducted by Lanius et. al. (2004), traumatic imagery vs. neutral imagery was measured by fMRI functional connectivity analyses to determine if differences existed between patients with and without PTSD.
- Scripti-Driven Imagery was used with 24 trauma patients
– 11 had PTSD (6 sexual assault, 5 motor vehicle accidents)
– 13 no PTSD (5 sexual assault, 8 motor vehicle accidents)
- All subjects scanned the traumatic and neutral imagery 3 times while instructed to
– (30 seconds) Lie still and focus on script of a traumatic or neutral event that they had experienced as the script of the event was being read to them;
– (60 seconds) Remember olfactory, auditory, somato-sensory, visual sensations as soon as the script was heard;
– (120 seconds) Lie still, breathe through nose, and let go of traumatic imagery
– Above script was repeated two times
Results of fMRI analyses yielded the following differences between PTSD vs. non-PTSD patients.
- PTSD Patients Experienced:
– Trauma memories as affect-laden memories in flashback form (e.g., reported feeling „I was back at the scene of the trauma“
– Increased heart rate during the script-driven imagery
– Increased right hemispheric activity consistent with a non-verbal pattern of memory retrieval
- Non-PTSD Patients Experienced:
– Trauma memories recall as non-affect-laden, autobiographical memories (in narrative form)
– Increased left-hemispheric activation consistent with verbal pattern of memory retrieval
– No increase in heart rate during script-driven imagery
Below is a list of physiological symptoms that people sometimes experience when they are feeling anxious or panicky. Please rate on the line next to each item how fearful you are of these symptoms using the numbers from 0 to 3 below. Please rate each item.
- N/A – Symptom not present
- 0 – Not at all fearful
- 1 – Somewhat fearful
- 2 – Quite fearful
- 3 – Extremely fearful
____ 1. Lightheadedness / dizziness
_____ 2. Shortness of breath
_____ 3. Wobbliness in legs
____ 4. Nausea
____ 5. Blurred / distorted vision
____ 6. Tingling in fingertips
____ 7. Numbness in arms or legs
____ 8. Heart palpitations
____ 9. Pressure / heaviness in chest
____ 10. Knot in stomach
____ 11. Lump in throat
____ 12. Dry throat
____ 13. Sweating
____ 14. Disorientation / confusion
____ 15. Sense of disconnectedness from body
Clinical observations suggest that a state of „abandonment panic“ may be triggered in borderline and narcissistic individuals when a here-and-now threat of abandonment is associated with earlier experiences of abandonment depression. The fear of abandonment depression is sufficient to trigger a panic response, as the individual feels the threat of being overwhelmed by the traumatic affect associated with memories and experiences of early abandonment. Thus, when borderline or narcissistic individuals experience the threat or signal of abandonment depression, they are often propelled to activate their seemingly dysfunctional, acting-out behaviours, in order to ward off the overwhelming feelings of abandonment depression (e.g., by outbursts of rage, suicide gestures or other self-injurious actions) which may then lead them to re-connect with care-givers, therapist, or significant others (e.g., via hospitalization, emergency therapy session) and a temporary remittance of the abandonment panic.
Dr. Mervin Smucker is an international trauma consultant and author of numerous articles and books on trauma and cognitive-behavioural therapy interventions.
Cognitive therapy is based on the underlying rationale that the way in which individuals interpret and structure their experiences determine in large how they think, feel, and act. The therapy involves teaching individuals a blend of verbal, visual, and behavioural modification techniques designed to help them to identify, reality-test, and correct their own distorted cognitions and the maladaptive beliefs underlying them. When a person is able to think and act more realistically and adaptively to here-and-now issues, problems, and situations, an amelioration in mood and overall functioning generally ensues. Thus, the primary goals of cognitive therapy are to:
- alleviate the emotional distress of patients by identifying and modifying their cognitive distortions, misinterpretations, self-defeating behaviors, underlying dysfunctional beliefs and maladaptive schemas.
- have patients learn to incorporate the therapeutic techniques of the therapist so that they can, in effect, become their own cognitive therapist; that is, they learn to alleviate their own negative moods by becoming trained to logically examine and modify their dysfunctional cognitions themselves.
The nature of traumatic memories has implications for how trauma-related material is accessed, confronted, and processed in psychotherapy. Traumatic memories are generally encoded and accessed differently from non-traumatic or narrative memories. In contrast to narrative memories, traumatic memories are more likely to:
- lack in verbal narrative and context;
- involve primary sensory stimuli (visual, kinesthetic, auditory)
- be encoded in the form of vivid sensations and images that are not accessible by linguistic means alone;
- be state dependent;
- be difficult to integrate via assimilation or accommodation because they are stored differently
- dissociated from conscious control
- “fixed” in their original form and remain unaltered by the passage of time.