The Importance of Accurate Diagnosis of Post Traumatic Stress.


As a specialist in trauma and Post Traumatic Stress, I read and research constantly for new information and treatment options in order to provide the best possible options for each person I have the fortune of working with.
 
The difficulty can be is that most individuals with PTSD suffer from other mental disorders as well. Studies of the prevalence of PTSD in large samples have found the following mental disorders are most likely to be co-morbid with PTSD:
 
  • Major Depression
  • Substance Use Disorders
  • Dysthymia – persistent mild depression
  • Agoraphobia
  • Obsessive-Compulsive Disorder
  • Generalised Anxiety Disorder
  • Panic Disorder
  • Somatisation Disorder – extreme anxiety about physical symptoms such as pain or fatigue
  • Antisocial Personality Disorder
  • Borderline Personality Disorder
  • Adjustment Disorder
  • Phobias
 
It can be challenging to determine whether overlapping symptoms are best conceptualised as being a part of the PTSD constellation of symptoms or whether they should be attributed to another disorder. Differential diagnosis can be especially difficult when disorders other than PTSD are preceded by exposure to traumatic stress.
 
Despite some symptom overlap between PTSD and other disorders, PTSD has a number of unique features that distinguish it from other disorders. DSM-5 provides specific differential diagnosis guidelines in order to help clinicians assign the most appropriate diagnoses. I know there is much controversy over the DSM, however it is useful to have some form of benchmark to work from.
 
The following elements are useful in distinguishing symptoms of PTSD from symptoms of other disorders:
 
  • PTSD symptoms start or get worse after exposure to a traumatic event.
  • Stimuli reminiscent of traumatic events that activate PTSD symptoms are often pervasive and wide ranging, as opposed to singular or highly specific as in the case of phobias.
 
Disorders other than PTSD may be caused, in part, by exposure to traumatic stress. Although stressor exposure is part of the PTSD diagnostic criteria, PTSD is by no means the only mental disorder that may develop in the wake of trauma exposure. Examples of disorders that may develop after or be exacerbated by trauma exposure include adjustment disorder and phobias. Other highly prevalent disorders, such as depression and panic disorder, may also be potentiated by a traumatic stressor.
 
It is important to look at the guidelines for making a differential diagnosis of PTSD versus other conditions that are commonly associated with traumatic stress exposure. PTSD can be distinguished from these disorders by its defining symptom criteria (i.e., to meet criteria for PTSD, individuals must demonstrate a symptom profile that is consistent with the guidelines for PTSD). Additionally, exposure to traumatic stress is a requirement for a diagnosis of PTSD; in contrast, for disorders such as depression, panic disorder and phobias, although symptoms may be associated with a traumatic event, this is not a requirement.
 
This is why it is important to gather information from varying sources using a variety of methods in order to ensure an accurate diagnosis which will enable the best possible treatment for all symptoms for each individual.

Changes In Treatment Approaches For PTSD


Below is an article taken from the APA website that I find extremely interesting and reassuring that the military is not restricting themselves to CBT and EMDR in treating serving personnel struggling with PTSD.

A psychodynamic treatment for PTSD shows promise for soldiers
March 2012, Vol 43, No. 3
Print version: page 11

PTSD
While cognitive-behavioral therapy remains the most well-researched treatment for post-traumatic stress disorder, it doesn’t help all patients. That’s especially true for service members who have been perpetrators as well as victims of violence, says Russell B. Carr, MD, an Army psychiatrist.
“It’s a much more complicated experience, and they often feel a lot of shame in addition to the usual PTSD symptoms,” he says.

For the past six years, Carr has been working with soldiers who haven’t responded to cognitive-behavioral therapy, and he’s developed a new treatment rooted in intersubjective systems theory. This modern take on psychoanalysis pioneered by Robert Stolorow, PhD, posits that the heart of trauma is shame and isolation.
Carr’s therapy, described in the October 2011 issue of Psychoanalytic Psychology, has shown promise helping soldiers who haven’t responded to CBT by addressing the existential dread dredged up by trauma, and the feeling that their entire world has lost meaning. Though Carr’s goals are ambitious, his intervention is relatively short—requiring twice-weekly sessions for up to three months. As a result, the therapist must clearly define goals, keep conversations on track and quickly establish rapport with clients, Carr found.

Short-term therapy—which is typical of CBT, but less common with psychoanalytic approaches—is often the only option in military settings, he says.
“In the military, there is frequently the situation where a patient or therapist is leaving soon,” says Carr. “It’s a transient population, and it limits the length of time we have to work together.”

A key part of intersubjective therapy is helping clients put their feelings around traumatic experiences into words. These feelings aren’t always negative. One patient described in the article found he enjoyed the smell of burning human flesh, and was later horrified and ashamed of his initial reaction. By expressing empathy and not rejecting the soldier, Carr helped the soldier process the experience and reconnect with the civilian world.

Convincing soldiers that a therapist—as well as friends and family—can understand a little of what they are going through lessens their PTSD symptoms, Carr found. In some cases, soldiers even learn from the experience, he says. “Recognizing the fragility of life, you can refocus on what’s important to you, and not waste time on things that aren’t.”
—S. Dingfelder

PTSD Treatment Research Project


As you may well know, I am a therapist, coach and trainer based up in the North east of Scotland and run a private clinic that specialises in trauma and PTSD. I have worked with people from all walks of life and helped them move beyond the PTSD and onto a happy and satisfying life again. PTSD is not restricted to purely the military, it affects anyone that has experienced one or more traumatic events regardless of who you are or what you do and the great thing is that it does not have to last forever, there are ways to resolve the trauma and live a normal life. It is through retraining your brain to process these memories differently that dissolves the physical and psychological symptoms that are caused by the psychological injury that results from the traumatic event/s.

I am now in the final stages of designing a PTSD Research Project up in Aberdeenshire to document the treatment method that I have been developing based on the outstanding work of various leaders in the fields of psychology, psychotherapy, NLP and Neuroscience. My ultimate aim is to have the project independently assessed and use the evidence to generate funding locally in order that the project can then be replicated around the region and help as many people as possible.

I am now starting to look for volunteers for this project and keen for a wide spectrum of volunteers from military and civilian populations. I am very keen for volunteers from all emergency services, however, if you or someone you know would like to participate and receive free treatment for existing PTSD, this needs to have been diagnosed, and I will need your permission to discuss this with your GP and mental health professional if you are currently in their care.

Please email me at simon@simonmaryan.com to arrange an initial meeting to assess whether your participation is beneficial for you or if there are any contraindications that could exclude you from the project.

I will update again when the project is ready to start and provide dates etc.

Simon

Addictions and Hypnosis


Addiction-300x232

This is a subject that is highly relevant to my work at the moment as I am involved in a pilot project in Aberdeenshire working with drug and alcohol addiction, so I have been re-reading these research papers again myself. There are many levels to addiction and also influence from and transference from other presenting issues in an addicts lifestyle that can complicate the recovery process.

So What is the difference between a habit and an addiction?

Addiction – there is a psychological/physical component; the person is unable to control the aspects of the addiction without help because of the mental or physical conditions involved.

Medical News Today wrote a great article about addiction.

People with an addiction do not have control over what they are doing, taking or using. Their addiction may reach a point at which it is harmful. Addictions do not only include physical things we consume, such as drugs or alcohol, but may include virtually anything, such abstract things as gambling to seemingly harmless products, such as chocolate – in other words, addiction may refer to a substance dependence (e.g. drug addiction) or behavioral addiction (e.g. gambling addiction).
http://www.medicalnewstoday.com/info/addiction/

Habit – it is done by choice. The person with the habit can choose to stop, and will subsequently stop successfully if they want to. The psychological/physical component is not an issue as it is with an addiction.

This is a fascinating topic that I hope you will again find interesting reading in terms of the application of and the success in the use of hypnosis. 

Study 1: Hypnosis and Cocaine
Hypnosis For Cocaine Addiction Documented Case Study
http://www.ncbi.nlm.nih.gov/pubmed/8259763

Notes: Hypnosis was successfully used to overcome a $500 (five grams) per day cocaine addiction. The subject was a female in her twenties. After approximately 8 months of addiction, she decided to use hypnosis in an attempt to overcome the addiction itself. Over the next 4 months, she used hypnosis three times a day and at the end of this period, her addiction was broken, and she has been drug free for the past 9 years. Hypnosis was the only intervention, and no support network of any kind was available.

American Journal of Clinical Hypnosis, 1993 Oct;36(2):120-3
By: G. W. Handley, Ohio State University, Lima, OH USA 45804

Study 2: Hypnosis and Methadone
A comparative study of hypnotherapy and psychotherapy in the treatment of methadone addicts.
http://www.hypnosis-review-quarterly.com/drug-addiction-hypnosis-studies.html
http://www.ncbi.nlm.nih.gov/pubmed/6486078

Notes: Significant differences were found on all measures. The experimental group had significantly less discomfort and illicit drug use, and a significantly greater amount of cessation. At six month follow up, 94% of the subjects in the experimental group who had achieved cessation remained narcotic free.

American Journal of Clinical Hypnosis, 1984; 26(4): 273-9
By: A. J. Manganiello

Study 3: Hypnosis and Marijuana, Cocaine and Alcohol
Intensive Therapy: Utilizing Hypnosis in the Treatment of Substance Abuse Disorders.
http://bscw.rediris.es/pub/bscw.cgi/d4584094/Potter-Intensive_therapy_Utilizing_hypnosis_substance_abuse_disorders.pdf

Results: All subjects were given 20 daily hypnosis sessions and then followed up a year later where it was found that using hypnosis in this fashion led to a 77% success rate.

Notes: This paper reports on 18 cases over a 7-year period where hypnosis was used to treat a variety of addictions. Fifteen cases involved alcohol, two involved cocaine and one involved marijuana. All subjects were given 20 daily hypnosis sessions and then followed up a year later where it was found that using hypnosis in this fashion led to a 77% success rate.
Tools: The following tools and suggestions are given for use in hypnosis;

(A) Direct Suggestion. Direct suggestion can be used for creating a positive expectancy. The therapist can also use direct suggestion to inspire confidence, commitment, motivation, and perseverance in the client to achieve the stated goals, as well as encourage the proper behavioral changes.

(B) Anchors. In hypnosis, anchoring happens when a posthypnotic suggestion is paired to a feeling state. Therefore, when an individual has a craving for the drug, the posthypnotic suggestion is used to bring about the anchored feelings

(C) Metaphors A metaphor used in therapy usually consists of a story that has a short metaphor embedded within. The whole story is not metaphoric, but captures the client’s attention so the metaphoric message can be subconsciously embedded. For example, Wallas’s (1985) “The Boy Who Lost His Way.” All metaphors are altered, paraphrased and structured to fit the individual’s situation in order to make a therapeutic impact. For example, for female clients “the boy” in the metaphor becomes a girl.

(D) Reframes. There may be many issues that arise while working with addictions that can be reframed. For example, the way a person views New Year’s Eve; or what it means to go fishing or boating. Any situation in which the client has consumed alcohol or used their drug of choice can be reframed to exclude the substance.

(E) Affect Bridge. The affect bridge (Watkins, 1971) is used with clients who have particular emotions associated with the use of drugs. By following the emotion through the affect bridge to the first time the client felt that particular emotion before using the drug, the client can become more aware of and break the connection with that emotion and the drug.

(F) Self-hypnosis Self-hypnosis is routinely taught to all clients. It is left up to the clients as to how they use it.

American Journal of Clinical Hypnosis, Jul 2004 vol.47(1) :21-28
By: G. Potter

Study 4: Self-Hypnosis for Drug and Alcohol Abuse
Self-Hypnosis Relapse Prevention Training With Chronic Drug/Alcohol Users: Effects on Self-Esteem, Affect. and Relapse.
http://www.ncbi.nlm.nih.gov/pubmed/15190730

Results: While the rate of relapse for all four groups was roughly the same (13%), those who were taught self-hypnosis and who listened to self-hypnosis recordings at home 3 to 5 times a week were more serene, had higher levels of self-esteem, and had greater control over anger and impulsive behavior.

Notes: This study recruited 261 veterans who were admitted into a residential program for substance abuse. The aim was to find out if self-hypnosis could help chronic abusers of drugs and alcohol improve their sense of self-esteem, control their emotions and prevent relapses. Participants were broken into four groups and were assessed before and after they entered the program and then again 7 weeks later.

American Journal of Clinical Hypnosis 2004 Apr;46(4):281-97
By: R. J. Pekala, R. Maurer, V. K. Kumar, N. C. Elliott, E. Masten, E. Moon, M. Salinger, Coatesville VA Medical Center, Coatesville, PA 19320-2096, USA

Study 5: Case Study – Hypnosis for Chemical Dependency (and future related Imagery)
Refraining of an Addiction via Hypnotherapy: A Case Presentation
http://www.tandfonline.com/doi/abs/10.1080/00029157.1991.10402944#preview

Notes: “A chemically dependent man was treated using hypnotherapy and related psychotherapeutic techniques The majority of the sessions focused on age regressing the patient to events correlating to drug and alcohol abuse. During these events I introduced myself via hypnosis as “the voice from the future” to redefine the events and extract the useful learnings. With a new-found positive self-image, the patient was hypnotically age progressed to review future scenes. In each scene he successfully abstained from drug and alcohol use. The patient remained drug and alcohol free during treatment and the 6-month and one-year follow-ups.”

American Journal of Clinical Hypnosis, Volume 33, Issue 4, 1991, pages 263-271
By: David J. Orman

Study 6: Hypnosis and Heroin
The use of hypnosis with an injecting heroin user: brief clinical description of a single case
http://onlinelibrary.wiley.com/doi/10.1002/ch.69/abstract

Notes: This paper describes the use of hypnosis with an injecting heroin user. This client was finding it very difficult to keep to his methadone prescription and was frequently using heroin ‘on top’. He received three sessions of hypnosis in order to facilitate relaxation and visualization, and resolution of ambivalence concerning his drug use. The results suggest the client has responded well to treatment. Details both of the client and of the three hypnosis sessions are given and the outcome is discussed.

Contemporary Hypnosis, Volume 13, Issue 3, pages 198-201, October 1996
By: Bill Drysdale, Clinical Psychologist, Barnet Drug and Alcohol Service, Woodlands, Colindale Hospital, Colindale Avenue, London, NW9 SHG

Addiction-CyclesAdditional References:

http://www.mentalhealthy.co.uk/addiction

https://www.psychologytoday.com/basics/addiction

http://www.actiononaddiction.org.uk/home.aspx

http://www.bps.org.uk/search/apachesolr_search/Addiction

PTSD and Hypnosis


Over the last year I have been conducting my own meta-analysis of the efficacy of hypnosis in the treatment of a wide variety of different conditions (47 in total) as you can see below.

Hypnosis Research Articles

With my area of expertise being PTSD and Trauma, I could not miss an opportunity to dig deeper into this field and as with all the other subjects, I found that hypnosis either outperformed other modalities or greatly enhanced their performance in the treatment of the illnesses and conditions listed in my research. The papers and articles referenced in the links are available for you to read at your leisure and make your own conclusions, however, in the course of my research I have reinforced and deepened my understanding and belief that hypnosis is a hugely powerful form of treatment for so many afflictions of the human mind, body and spirit.

Study 1: Hypnosis and Combat-Related Post Traumatic Stress Insomnia (Hypnosis As Effective or Better Than Ambien)

Hypnotherapy in the Treatment of Chronic Combat-Related PTSD Patients Suffering From Insomnia: A Randomised, Zolpidem-Controlled Clinical Trial

http://www.medecine.ups-tlse.fr/du_diu/fichiers/ametepe/1212/PTSD_et_Insomnie.pdf
http://www.tandfonline.com/doi/abs/10.1080/00207140802039672

Results: Those in the study given hypnotherapy had improvement in all sleep variables assessed: quality of sleep, total sleep time, number of awakenings during the night, ability to concentrate upon awakening and morning sleepiness. The hypnotherapy group had better quality of sleep, better concentration, and lower sleepiness than the group that received Zolpidem (a prescription insomnia medication sold under brand names such as Ambien). The hypnotherapy group and the group given Zolpidem had equal levels of improvement for total sleep time and number of awakenings.

Notes: This study evaluated the benefits of add-on hypnotherapy in patients with chronic PTSD who were suffering with chronic difficulties in initiating and maintaining sleep, night terrors, and nightmares. Thirty-two PTSD combat veteran patients treated by SSRI antidepressants and supportive psychotherapy were randomised to 2 groups: 15 patients in the first group received Zolpidem 10 mg nightly for 14 nights, and 17 patients in the hypnotherapy group were treated by symptom-oriented hypnotherapy, twice-a-week 1.5-hour sessions for 2 weeks. The hypnotherapy included age regression where participants imagined returning to earlier periods in which normal restorative sleep was present (for example, an exhausting day of games with friends during childhood). All patients completed the Stanford Hypnotic Susceptibility Scale, Form C, Beck Depression Inventory, Impact of Event Scale, and Visual Subjective Sleep Quality Questionnaire before and after treatment.

International Journal of Clinical and Experimental Hypnosis, Vol. 56, Issue 3, 2008
By: Eitan Abramowitz, Yoram Borak, Irit Ben-Avit et Haim Y. Knobler, Israel Defense Forces, Mental Health Department, Israel

Study 2: Hypnosis for PTSD in Children Traumatized by Death of Close Relatives
Hypnotic Treatment of PTSD in Children Who Have Complicated Bereavement.

http://www.asch.net/portals/0/journallibrary/articles/ajch-48/iglesias.pdf

Results: Following the single session hypnosis, the mother reported significant improvements in her son’s skin with noticeable changes in itching, irritation, and swelling. The dermatologist was impressed with the child’s recent progress. According to the mother, at follow up, her daughter was feeling increasing relief from the abdominal discomfort. She was no longer debilitated by pain, which had narrowed her range of activities. Follow-up a month later was conducted by phone with the mother and she reported that both children had recovered completely from the debilitating somatisation (that is, the production of recurrent and multiple medical symptoms with no discernible organic cause) features. The children were no longer demonstrating intrusive morbid ideations of the course of their father’s death and were no longer experiencing obsessive preoccupations over the degree of terror and agony their father must have endured during the course of the traumatic events that led up to his death. The mother indicated that at this juncture both children were also able to reminisce about happy times with their father. The mother at this follow-up also reported the restart of grief in both children and assured us that her family would offer comfort for their mourning. (Note—It was suspected that the traumatisation/PTSD had been interfering with the children’s ability to complete normal grieving and move on, so this was a good sign.)

Notes: This paper reports on two cases where children were suffering from Post Traumatic Stress Disorder (PTSD) as a result of the traumatic death of close relatives in rural Guatemala. The normal grieving process had been inhibited due to the horrific nature of these deaths and the children’s grief had become a pathological psychiatric disorder. Both children were only treated with a single session of hypnosis involving the Hypnotic Trauma Narrative (a protocol the authors developed specifically to help children deal with situations like this). There was a follow-up one week later and again after two months when the authors noted that the children’s symptoms had cleared and they were now beginning to grieve in a normal fashion.

The hypnotic induction consisted of simply asking the children to close their eyes. The following “Hypnotic Trauma Narrative” was then used: You’re old enough to know that when you look through telescope things that are far away look much closer. Important events in our lives can also be viewed as though you were looking through a telescope that brought them close to you. When you do that, you gain access to even the minutest details of the image that you are examining. At that point, you could see more than you need to see and could become stuck with certain images and unable to let them go. This can be overwhelming because the details that you seem stuck on are upsetting and hurtful. There is an alternative—you can turn the telescope around and view the same picture form the wide lens and then things can seem very, very far away. When that happens, you may not realise it, but many details of the image that you are examining get lost and are no longer available. Events that take place in life can be examined from either end of the telescope…. Now, I ask that you see yourself looking through the wide lens of a telescope at events that have taken place in your life, that need to be viewed from a less painful perspective, so that you can be well again. Look through the eye of your mind into the wide end of the telescope. This offers you the ability to see things in a far away, far away, far away space, place, and time.

By placing them far away, you’re able to see them in a more manageable fashion and elements of that image that used to upset you, are no longer so noticeable. Of course, horrible events in our lives do not simply disappear, but with the passage of time the details of the painful event get blurry, you start forgetting, and your mind makes room for current memories. Your mind is also capable of giving you a picture of yourself a week from today, a month from today, three months from today, and even a year from today…It’s fun to be able to look ahead and to get a glimpse of what our lives will be like in the future. As we now look ahead…. and I wonder if you are able to project ahead a week…. I wonder if you can move ahead a month or two or three, and I wonder if you are old enough to be able to see a year into the future. As you look ahead, no matter how far into the future, you find yourself able to accept all of the happy memories that you have not given yourself the opportunity to enjoy. As you put everything that is painful in its proper perspective, you grow and strengthen inside, as well as outside, and you become more mature and older. Also, any complaints that your body has been voicing that are no longer necessary can quietly follow in the same direction as the images that you are looking at through the wide lens of the telescope. As these complaints become a thing of the distant past, never to trouble you again, you become well and able to move ahead with the assignments that are appropriate for someone your age.

Am J Clin Hypn. 2005 Oct-2006 Jan;48(2-3):183-9
By: A. Iglesias, Virginia Commonwealth University

Study 3: Hypnosis for “Complex Trauma” PTSD (such as from childhood abuse, sexual assault, and domestic violence)
Hypnosis For Complex Trauma Survivors: Four Case Studies

http://bscw.rediris.es/pub/bscw.cgi/d4438997/Poon-Hypnosis_complex_trauma_survivors.pdf

Results: Data from self-reports, observation and objective measures indicate a significant reduction in the trauma symptoms of these four subjects after hypnosis treatment.
Notes: This report describes the use of hypnosis to help four Chinese woman who were suffering from complex trauma. Two were victims of sexual abuse when they were children, the third had been raped and the fourth had been repeatedly battered by her husband. The hypnotic treatment involved three steps: “stabilisation, trauma processing, and integration.” Hypnosis was first used to help stabilise the victims. Then age regression techniques were used to help them to remember the traumatic events that led to their condition (and to begin to distance themselves from these memories). Finally, hypnosis was used to help them integrate and consolidate the gains they had made. When their treatment was finished they were all assessed by various self-reported and objective measurements. These all indicated that they experienced a significant reduction in their symptoms as a direct result of this hypnotic treatment. One key thing to note is that the researchers comment that adequate rapport and explanation about hypnosis must be provided before clients feel comfortable to use the tool, especially in survivors of childhood abuse who tend not to trust people easily.

Am J Clin Hypn. 2009 Jan;51(3):263-71
By: Maggie Wai-ling Poon, Clinical Psychologist, Social Welfare Dept. Hong Kong

Study 4: Hypnosis for PTSD in Immigrants who Escaped to America After Being Tortured, Raped and Abused
Indirect Ego-Strengthening in Treating PTSD in Immigrants from Central America.

http://www.readcube.com/articles/10.1002/ch.227?locale=en

Results: This report focuses on the limitations of conventional therapy to help these individuals and it presents two ego-strengthening techniques involving indirect hypnosis that have proved helpful in treating this population.

Notes: As a result of civil war in Central America many refugees escaped to America suffering from PTSD as a result of being tortured, raped and abused.
Contemporary Hypnosis Vol. 18(3):135-144

By: G. Gafner, S. Benson, Southern Arizona Veterans Affairs Health Care System, Tucson Arizona; Progressive Insurance Employee Assistance Program, Temple, Arizona

Please feel free to comment and discuss the findings and any experience you have had either personally with PTSD and Trauma or in treating people who are struggling with it, as I would love to hear about different experiences and view points.