A Case Of PTSD & EMDR

Dr Andy Kinch Locum Consultant Psychiatrist

AimsPresentation of caseTreatment InvolvedOverview of EMDR Therapy

Case of PTSDPatient details/ source of referral:

◦ 42 year old lady,not currently in a relationship◦ Referred by her manager (July 2014)

Presenting complaint:◦ Following an assault by a client with a severe and

enduring mental illness at work in June 2014 patient was triggered to re-remember a vicious murderous assault by ex-boyfriend just before Christmas 2013 .

◦ Current symptoms include initial insomnia,irritability,nightmares,depressive symptoms and anxiety about returning to work

◦ Felt low last 4 weeks .

History of presenting complaint:◦In June 2014 client was unexpectedly

seriously assaulted by a resident of the home she worked in.

◦She was cleaning a fridge contained within a walk-in cupboard where food was kept for residents when a tall,male resident came at her from the back,grabbed her by the arms and she could not push him off.

◦He then let go,roared and grabbed a stack of chocolate and fled.

Initial assessment July 2014

HPC continued…◦She was triggered to re-remember an

assault perpetrated by an ex-boyfriend in England in December 2013 where they had been on holiday.

◦She had known him for 8 months.◦He was drunk and on drugs;she was

asleep. There had been no argument.◦She woke up to find him calling her

names,looking like a devil and he began to punch and strangle her.He produced a knife.A calmness came over her despite the thought that she was going to die.

HPC…◦She could not breathe ;he began cutting

her.◦She remembered her work training with

regard to assaults.◦She managed to engage him when he

said she was bleeding.◦He let her go ,she lifted her bag,fled the

room and dialled 999.◦Unbeknown to her ,he had a history of

domestic abuse though he had never been formally charged.

◦She denied any current thoughts that life was not worth living.

Past Medical History:◦Nil of note.

Past Psychiatric History:◦Nil of note.

Family Medical History:◦No family history.

Family Psychiatric History:◦No issues

Drug History:◦On no medication,no known allergies

Personal History:◦ Childhood:

Born in County Tyrone Normal vaginal delivery Normal developmental milestones Enuretic as a child. Many siblings

◦ Education: Bullied at primary school over glasses No major problems at secondary education and left

at 16

◦ Occupation always worked

Psychosexual History:◦ Pregnant aged 17◦ Married this man but he was alcoholic and

domestically violent;she left him after 4 years

Forensic History:◦ Nil of note

Social History: living with mother and daughter. Husband works as a taxi driver.

Alcohol & Drugs:◦ Drinks alcohol socially No history of previous or current illicit drug use

Premorbid personality:◦ Humerous, spontaneous, outgoing and strong.

Mental state examination:◦Pleasant◦Kempt◦Not agitated◦Reasonable eye contact and rapport.◦Subjectively anxious,objectively

euthymic◦No TLNWL◦Insight- reasonable

Working Diagnosis:

◦Post Traumatic Stress Disorder(PTSD)

Treatment plan:◦ EMDR◦Initially resource installation◦EMDR logbook given to patient◦Given questionnaire to complete

DES (Dissociative enquiry scale)

Progress during treatment

1st Session 13/6/14◦2 indecent assaults perpetrated

upon her when aged 19 and 32◦DES 12.5%◦Peaceful place installed◦Both indecent assaults had

Subjective Unit of Disturbance(SUDS) of less than 5(0-10 scale,0 being no disturbance and 10 being the maximum disturbance now)

Negative Cognition “I’m to blame”Positive Cognition “I’m not to blame”Rapid processing took place and SUDS rapidly went to 0 and the Validity of cognition(VOC) went to 7(applied to positive cognition,1 meaning it feels totally false to client now and 7 meaning it feels completely true)Positive cognition was installed and body scan was clearTherefore “small t” trauma processedClient now has faith in EMDR established and therapeutic alliance is strengthened.

2nd session: 20th June 2014◦Worst memory of assault by ex-boyfriend

was “being strangled and not being able to breathe”

◦Negative cognition identified,I’m going to die,SUDS 8.

◦Positive cognition,I’m alive,I survived,Validity of Cognition(VOC)5(1 meaning the positive cognition is totally false now and 7 meaning it’s totally true now)

◦Body sensations associated with memory were chest pain,extremely dry mouth and feeling extremely nauseous

◦Emotions associated with Assault;extreme fear.

◦Floatback protocol used;looking for an earlier time when she had the same fear,same negative cognition,same body sensations

◦She floated back to a car accident when she was in early pregnancy aged 17 with ex-husband driving

◦This was processed first using EMDR ◦First memory after first set; car

flipping over in slow motion

SUDS 2VOC 7Second memory after second set “hands up to the window screen”Third memory after third set “car complete write-off”Positive cognition after fourth set “it’s something that happened ,it’s in the past,I’m in control”Positive cognition “I survived,I’m in control”installed

◦Processing of murderous assault can now take place

◦Initial SUDS of 9 with respect to “I’m going to die” and VOC of 3 with respect to “I’m alive,I survived”

◦After just one set,SUDS went to 6 and VOC to 7

◦After next set,SUDS to 0/1 and VOC to 7◦Without any help from me ,her cognitions

soon went to “it does not matter what he does,I’m going to survive”

◦It then quickly went to “I’m not taking this sh*t effect me,I’m indestructible”

This became the positive cognition which was then rapidly installed and body scan when checked was clear.

Trauma now processed and assault at work when checked had also processed as a secondary generalisation effect

Final session which took place a week later was to check that she remained processed(she did) and to work on future template

Her final words were “I’m in control,you’re never going to do this to me again,I’m indestructible,it’s something that happened,it’s in the past,I’m the strong one”

Eye movement desensitisation and reprocessing therapy

Dr Andy KinchEMDR Therapist and Locum Consultant Psychiatrist 22nd October 2012

EMDR1987 - Shapiro “walking in the park”

discovered the effects of spontaneous eye movement and developed procedures around effects of eye movement

1989 – first controlled study published in Journal of Traumatic Stress

1990 – other forms of bilateral stimulation also had positive effects

Research – over a dozen randomised controlled treatment outcome studies

Mechanism – neurobiological underpinnings are unknown for any form of psychotherapy

Model – independent of particular neurobiological mechanism. It interprets clinical phenomena, predicts successful applications, guides clinical practice

Methodology – standardised procedures and protocols guided by articulated principles

How does it work?Theory that eye movements are linked with

hippocampus which is linked to consolidation of memory

Trauma memory stored differently than ordinary memory; in the right hemisphere, in fragmented, unintegrated form

Psychological trauma causes disassociation of hemispheric processing

Trauma memory only encoded as implicit memory in the right hemisphere

Terror blocks hippocampus so that information does not go to explicit memory

Decreased hippocampal volume in chronic PTSD Synaptic pruning

Two types of trauma◦Small t trauma – experiences that give

one a lesser sense of self confidence and assault one’s sense of self efficacy

◦Big t trauma – life threatening

Theory ◦Body-mind – natural information

processing system. Mind like body physiologically geared toward health unless blocked. When confronted with a trauma information processing systems get interrupted

EMDR therapy is a psychotherapy approach (distinct from psychodynamic, CBT, etc) guided by an information processed model

Processing is viewed as the forging of adaptive associations between networks of information stored in the brain

EMDR incorporates an associative process that allows the relevant connections to be made

Memory networks are viewed as the underlying basis of pathology for mental health

MethodEMDR therapists activate clients’

information processing system by focusing on a ‘target’ related to the trauma such as◦The memory with it’s worst image◦The emotions associated with it◦The body sensations (there is always

a somatic memory of the trauma)◦The negative believes associated

with it

Method continuedAfter the memory network is stimulated

add bilateral stimulation (BLS)This stimulates accelerated information

processingResults in a rapid free association of

information where they find insight and understanding

Each set of BLS further unlocks disturbing information and accelerates it along an adaptive path until clients return to a state of equilibrium and integration

Some clients process so rapidly that it is hard for the therapist to believe it

Adaptive information processing model

Trauma

Traumatic memory becomes blocked at

neurophysiological level EMDR

Adaptive resolution

Targeted memory linked with more

adaptive information

Loosening up of frozen memory

network

Reconfiguring or rebalancing of

neurophysiological state

Information processing of the components of distressing memory

Eight phases of EMDR treatment

1. Client history2. Client preparation (including

resource installation3. Assessment4. Desensitisation5. Installation6. Body scan7. Closure8. Re-evaluation

EMDR does not move anything that is useful or necessary

EMDR unlocks what is natural within each of us

It is our innate healing process that has been blocked and can be unblocked with EMDR

EMDR transforms psychological memory to objective memory (that is functional, devoid of emotional charge and not self-referential)

Memories are no longer alive in the present, rather they are experienced as belonging to the past, remembered simply as facts

During EMDR clients develop an attunement to their own inner wisdom which they had been taught to censor or discount as children

EMDR therapists work with memory networks

Ego states are also memory networks

EMDR integrates child memory networks with adult memory networks

PTSD1. People with PTSD don’t attend to neutral

stimuli, their brains are geared to traumatic stimuli

2. People with PTSD have more active limbic systems and ordinary talk PT does not decondition the limbic system

3. With PTSD there is a loss of the capacity to analyse and categorise arousing information. People with PTSD cannot talk about their experience. The left hemisphere is locked out. Reason is absent and there is an increased emotional response

PTSD continued

4. People with PTSD are not able to utilise language to gain distance from the offending stimulus

5. Fragmented or misclassified sensations are reactivated in state dependent form with PTSD (traumatised people are triggered by internal or external reminders of original trauma)

DSM-5 removing diagnosis of BPD and reclassifying as complex PTSD

Dissociation is the most important concept of all to understand and should be used to assess what therapy an adult survivor of sustained childhood sexual, physical or emotional abuse or neglect should have