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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
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