Special populations
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Special populations. Headaches CRPS/Complex trauma GAD UTI/ Vaginismus Complicated bereavement. Headaches. One of most common pain complaints 1 year prevalence rate 12-14% (migraine) Often a symptom of trauma 25% of headache sufferers (migraine clinic) have PTSD

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Special populations

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Special populations

Special populations

  • Headaches

  • CRPS/Complex trauma

  • GAD

  • UTI/Vaginismus

  • Complicated bereavement

Mark Grant


Headaches

Headaches

  • One of most common pain complaints

  • 1 year prevalence rate 12-14% (migraine)

  • Often a symptom of trauma

  • 25% of headache sufferers (migraine clinic)

    have PTSD

  • 50% of combat veterans

  • Higher likelihood of physical or sexual abuse

Mark Grant


Headache case

Headache case.

Mark Grant. MA, MAPs


Emdr targets

EMDR ‘targets’

Mark Grant MA


Emdr present pain

EMDR (present pain)

Mark Grant


Caution

Caution!

When is a headache not a headache?

  • Sudden onset

  • Non-responsive to medication

  • Other symptoms (seizures, changes in vision or hearing)

  • Aggravated by coughing or sneezing

Mark Grant MA


Crp rsd

CRP/RSD

  • Trauma can be a predisposing factor following injury

  • Median PTSS-10 score similar to trauma survivors (118 patients)

  • Similar neurological profile to PTSD

  • CRPS has been reported to be elicited by stress exacerbation in patients with PTSD

    (Huge et al, 2011)

Mark Grant MA


Crps complex trauma

CRPS/complex trauma.

Mark Grant. MA, MAPs


Emdr targets1

EMDR targets

Mark Grant MA


Emdr present pain1

EMDR (present pain)

Mark Grant


Elements of treatment complex trauma

Elements of treatment (complex trauma)

  • Extended preparation stage

  • Teaching of grounding techniques

  • Addressing ‘fear of feelings”

  • Teaching client how to self-soothe instead of self-injure

  • Teaching client how to attend to their pain by showing appropriate care and concern

  • Challenge feelings of unworthiness

  • Developing resources

  • Ego-state work

Mark Grant. MA, MAPs


Generalized anxiety disorder

Generalized Anxiety Disorder

  • Prevalence = 2 - 5% of general pop’n

  • DSM criteria somatic symptoms; restlessness, fatigue, concentration problems, irritability, muscle tension and sleep disturbance.

  • Often associated with somatic complaints such as low back pain and headaches and insomnia

  • One study found 50% of IBS sufferers also had GAD

  • 17% of PTSD sufferers also have GAD

Mark Grant MA


Gad case

GAD case.

Mark Grant. MA, MAPs


Emdr targets2

EMDR targets

Mark Grant MA


Emdr present pain2

EMDR (present pain)

Mark Grant


Uti vaginismus

UTI/vaginismus

  • Trauma is a predisposing factor

  • 1 in 5 women will have a UTI in lifetime

  • Women sufferers more than twice as likely to report some form of sexual molestation during childhood

  • UTI can lead to or exacerbate vaginismus

Mark Grant MA


Uti vaginismus case

UTI/vaginismus case.

Mark Grant. MA, MAPs


Emdr targets3

EMDR targets

Mark Grant MA


Emdr past trauma

EMDR (past trauma)

Mark Grant


Complicated bereavement

Complicated bereavement

  • Pain is symptom of trauma

  • Prevalence = 2% of normal pop’n

  • 20% of soldiers from Afghanistan, Iraq

  • Physical symptoms can include shortness of breath, heart palpitations, headaches, lethargy

    Health issues (increased risk of);

    • cancer,

    • cardiac problems,

    • suicidality ,

    • substance abuse

Mark Grant MA


Complicated bereavement1

Complicated bereavement

Mark Grant. MA, MAPs


Emdr targets4

EMDR targets

Mark Grant MA


Emdr past trauma present pain

EMDR (past trauma + present pain)

Mark Grant


Key points

Key points:

  • Although triggered by current stress/trauma, Pain is often a symptom of earlier trauma.

  • Target sequence addresses both past trauma and present pain, depending on client readiness.

  • Target may incorporate past and present pain.

  • Reprocessing often starts with present pain because of safety issues (also easier to address past trauma after present pain is better managed).

  • Duration of treatment, outcomes and need for

    additional inputs depends upon complexity of trauma

Mark & Ana Grant


Complex trauma and pain

Complex trauma and pain

  • Victims of long-term sexual and physical abuse

  • Victims of emotional neglect

  • Victims of childhood abuse and neglect who have also suffered later trauma (eg; serious accident, rape, combat, workplace bullying)

    + injury, IIIness, disability

Mark Grant. MA, MAPs


Elements of treatment

Elements of treatment

  • Extended preparation stage

  • Teaching of grounding techniques

  • Address ‘fear of feelings”

  • Teaching client how to self-soothe instead of self-injure

  • Teaching client how to attend to their pain by showing appropriate care and concern

  •  Challenge feelings of unworthiness

  • Developing resources

  • Ego-state work

Mark Grant. MA, MAPs


Grounding techniques

Grounding techniques

Interpersonal:

  • “Its okay, you are safe now, you are here with me…”

    Somatic:

  • “Can you feel your feet touching the floor?”

  • ”Can you pay attention to your breathing..”

  • “look at your hands or feet.. you’re a big boy/girl now.”

Mark Grant. MA, MAPs


Addressing fear of feelings

Addressing fear of feelings

  • Facilitating accepting atmosphere (showing empathy, acceptance)

  • Psychoeducation about the meaning of feelings, including pain

  • Normalizing feelings, including feelings of wellness/feeling okay

Mark Grant. MA, MAPs


Self soothing techniques

Self-soothing techniques

  • Psychoeducation (teaching how to self-soothe instead of self-injure);

    “Pain means you are hurt and need help”

    “What does an animal do when its wounded”

    “Humans are the only creature capable of ignoring pain”

  • Developing self soothing strategies;

    “What things or places make you feel the most relaxed/safe/secure?”

    (hints; a trusted friend, a pet, a room or place, music, activity such as craft etc)

Mark Grant. MA, MAPs


Self care skills training

Self-care skills training

  • Attending to the pain experience;

    “Even though I can’t feel your pain, I can see you are hurting and I am going to TRY TO help you”

    “You’re not alone - I am here” (reparenting)

  • Addressing feelings of unworthiness;

    “What have you done that makes you so underserving of even basic medical attention/self-care?”

    “What have you done to feel that you only deserve to suffer.. forever?”

    “Everyone is entitled to a pain-free life”

Mark Grant. MA, MAPs


Body resource exercise

Body resource exercise

“I want you to mentally scan your whole body… and find a relaxed, calm place… somewhere that feels normal …and just notice how it feels there…maybe soft… warm…loose…maybe a certain size, shape or colour… just noticing how it feels…different to the rest of your body… and maybe you can get an image of how that calm place feels.. and that image can remind you that you can feel better”

Mark Grant. MA, MAPs


Pendulation

Pendulation

“Now I want you to notice the area of pain [or discomfort] … and notice how that feels… and when you have that clear enough … take your mind back to that relaxed, calm place …and notice how that feels again there… just noticing how it feels…and how different it feels to the pain …and then when you have got that clear, I want you to notice the pain again… and how it feels .. And whether it feels any different to before..”

and so on…

(Adapted from Peter Levine)

Mark Grant. MA, MAPs


Ego state therapy

Ego state therapy

  • “..based on the premise that personality is composed of separate parts, rather than being a homogeneous whole.  These parts (which everyone has) are called ego states.  The therapist learns to work directly with the state that can best benefit from change, rather than merely working with an intellectual, talkative state.”

    Emmerson,

Mark Grant. MA, MAPs


Solo mother with chronic pain

Solo mother with chronic pain

T: I can almost feel how heavy and defeated you must be feeling

CL: I do feel defeated – but I don’t want this to affect my children (staring into space)

T: You seem lost

CL: That’s how I feel - I dunno where I am at the moment

T: I guess you’re just taking things one day at a time – before the pain you sort of had your life figured out but now..

Mark Grant. MA, MAPs


Solo mother with chronic pain1

Solo mother with chronic pain

CL: (interrupts) No, I had it ALL figured out, I was in control of everything, now I can’t even be bothered cleaning the bathroom. I feel like a complete failure.

T: What about the children?

CL: Oh well of course I get up and make their breakfast and school lunch etc..

T: I’m hearing that there’s a defeated part, but that there’s also a part that won’t quit, who gets up and makes the children’s breakfast no matter how tired and defeated she feels..

Mark Grant. MA, MAPs


Solo mother with chronic pain2

Solo mother with chronic pain

Cl: That part is the only part I feel I have control over

T: have you ever thought how maybe those parts might compliment each other?

Cl: Huh?

T: Well the defeated part is telling you to rest, but then the ‘in control’ part tells you to try harder, and motivates the responsible part to keep looking after the children.

Cl: I never thought of things that way

T: What I’m saying is that you need BOTH parts;

Mark Grant. MA, MAPs


Solo mother with chronic pain3

Solo mother with chronic pain

T: ..and they need to work together, but at the moment they’re kind of pulling in different directions.

Cl: Uhuh

T: So what if the defeated part could say to the ‘in-control’ part, ‘I’m tired and I need a rest’ and the ‘in-control’ part could actually hear that and use it to pace yourself better?

Cl: I dunno…

Th: Actually, its already happening, you don’t do as much now so as to conserve energy for the children

Mark Grant. MA, MAPs


Solo mother with chronic pain4

Solo mother with chronic pain

T: The problem is that the ‘in-control’ part labels this as failure instead of seeing it as a form of self-preservation.

CL: Yes, that’s true

T: So if we could talk to the part that feels defeated first, what do you think it would say to the ‘in-control’ part?

CL: I simply can’t do as much as I used to be able to

T: And what would the control part say back?

CL: I have to adjust my expectations..

Mark Grant. MA, MAPs


Crp rsd1

CRP/RSD

  • Trauma can be a predisposing factor following injury

  • Median PTSS-10 score similar to trauma survivors (118 patients)

  • Similar neurological profile to PTSD

  • CRPS has been reported to be elicited by stress exacerbation in patients with PTSD

    (Huge et al, 2011)

Mark Grant MA


Crps complex trauma1

CRPS/complex trauma.

Mark Grant. MA, MAPs


Emdr targets5

EMDR targets

Mark Grant MA


Elements of treatment complex trauma1

Elements of treatment (complex trauma)

  • Extended preparation stage

  • Teaching of grounding techniques

  • Addressing ‘fear of feelings”

  • Teaching client how to self-soothe instead of self-injure

  • Teaching client how to attend to their pain by showing appropriate care and concern

  • Challenge feelings of unworthiness

  • Developing resources

  • Ego-state work

Mark Grant. MA, MAPs


Complex trauma case 2

Complex trauma case #2.

Mark Grant. MA, MAPs


Emdr targets6

EMDR ‘targets’

Mark Grant MA


Emdr target past trauma

EMDR target (past trauma)

Mark Grant


Hysteria

Hysteria

“A hysteric is someone who cannot tell a story.. At least a coherent story – a story whose disparate parts hang together. When a hysterics narrative reaches its climax it tends to hang fire … an explanatory scene is missing.”

Deborah Elise White, 1989

Mark Grant. MA, MAPs


Summary

Summary.

  • Long preparation phase; don’t start EMDR until affect tolerance evaluated and addressed.

  • Lots of resourcing (ego states)

  • Obtain consensus from the ‘parts’ for dissociated or DID clients

  • Start small (not even a small ‘t’)

  • “Baby steps” “Baby steps” “Baby steps”

  • Pacing - EMDR interspersed with…

  • Lots of re-evaluation, psychoeducation

    (Acknowledgment: Forgash & Knipe, 2008)

Mark Grant. MA, MAPs


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