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The European Network for Traumatic Stress Training & Practice

The European Network for Traumatic Stress Training & Practice. www.tentsproject.eu. Assessment, formulation and treatment planning for psychologically traumatised individuals. Learning Outcomes. Describe the essential components of a full assessment of a psychologically traumatised individual

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The European Network for Traumatic Stress Training & Practice

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  1. The European Network for Traumatic StressTraining & Practice www.tentsproject.eu

  2. Assessment, formulation and treatment planning for psychologically traumatised individuals

  3. Learning Outcomes • Describe the essential components of a full assessment of a psychologically traumatised individual • Describe the principles of formulation and treatment planning • Discuss the importance of understanding an individual’s presentation before commencing treatment

  4. Mental Health Assessment • Full history • Biological, psychological, social, risk • Mental state examination • Physical examination • Investigations as indicated • E.g. structured interviews, questionnaires • Other information • E.g. informant, medical records

  5. Full History 1 • History of presenting complaint • Open questions • What are the main problems? • Detailed history and symptom screen • Medication • Past psychiatric history • Past medical history

  6. Full History 2 • Family History • Personal History • Infancy and early childhood • School • Occupational history • Psychosexual • Present social circumstances • Hobbies • Drug and alcohol history • Forensic History • Premorbid Personality

  7. Mental State Examination • Appearance and Behaviour • Dress, clean, tidy, appropriate, rapport, eye contact, distracted, responsive, facial expression, posture, activity, movements • Speech • Rate, volume, content • Mood • Subjective, objective • Thoughts • Form, content, preoccupations, suicidal thoughts

  8. Mental State Examination • Perceptions • Illusions, hallucinations • Beliefs • Overvalued ideas, delusions • Cognitive Function • Memory, Orientation, Attention & concentration • Insight

  9. Structured Interviews and Questionnaires • Clinician Administered PTSD Scale (CAPS) • Revised Impact of Event Scale (IES-R) • Trauma Screening Questionnaire

  10. Assessment • Full history, examination, other information • Biological, psychological, social, risk • Standardised measures • CAPS, IES-R, PSS-SR • No assumptions • NB range of presentations • Explore history of trauma with examples • Re-experiencing and hyperarousal screen • Trauma Screening Questionnaire

  11. Formulation • Brief description of issues • Differential diagnosis • Predisposing factors • Precipitating factors • Maintaining factors • Further information required • Management Plan

  12. Management Planning • Consider evidence base • Involve individual • NB choice • Ensure address all factors elicited • Biological • Psychological • Social • Risk

  13. Gethin – 26 y.old male • RTA (MVA) in Cardiff 3 weeks ago (passenger in taxi) • Lacerated face • Required sutures • Referred to traumatic stress service by maxillo-facial surgeon • Upset in clinic • ?PTSD

  14. Initial Assessment 1 • Five weeks post trauma • Under influence of alcohol at time • Was not intoxicated • No evidence dependence • No alcohol since RTA • IES-R score 60

  15. Initial Assessment 2 • Symptoms started within days • PTSD and depression • Slowly reducing • Background • Happy childhood • No Personal or Family Psychiatric History • Insurance worker • Lives with long-term girlfriend

  16. Initial Assessment 3 • Very good social support • Functioning reduced • Off work • Will not go in car at night • Claiming compensation • Mental state reactive • Working diagnosis • Acute PTSD with depressive features

  17. Gethin - Initial Management • Education • Natural course of symptoms • Effectiveness of interventions • Rationale of TFCBT • Symptom monitoring • Do’s and Don’ts • Agreed monitoring 2 weeks fby reassess • If no better for TFCBT

  18. Review • Seven weeks • IES-R = 62 (from 60) • Completed symptom monitoring • Symptoms at same level • Education recap • Motivated to engage in TFCBT • Rationale re-discussed • Initial four sessions agreed

  19. Key Issues • Trajectory • Readiness for treatment assessed • Compensation • Work • Alcohol • Secondary depression

  20. Angela – 35 y.old female • Assaulted by partner two days ago • Repeated domestic violence • Returned to him • Upset • Doesn’t know whether to stay or go • Social services request psychological intervention

  21. Initial Assessment 1 • One week post index assault • Remains upset • Preoccupied with relationship • Planning to leave • IES-R score 60 • Existing symptoms • PTSD and depression • Increasing

  22. Initial Assessment 2 • Background • Traumatic childhood • With partner eight years • Increasing violence • No children • Poor relationship with family • Has never engaged with therapy

  23. Initial Assessment 3 • Very limited social support • Functioning reduced long-term • Not working • Does not socialise • Does household chores

  24. Initial Assessment 3 • Mental state • Very depressed, limited reactivity • Some suicidal ideation, no plans • Working diagnosis • Pre-existing depression • Chronic PTSD • Acute PTSD symptoms (not ASD)

  25. Continuing Threat and PTSD • Often complex issues • Phase one • Accommodation, benefits, separation, emotional stabilisation • Phase two • Trauma focused therapy • Phase three • Often integration to new situation

  26. Initial Management 1 • Education • Depression and PTSD • Natural course of symptoms • Effectiveness of interventions • Need for stabilisation first • Social • Psychological • Pharmacological • Benefits of multidisciplinary approach

  27. Initial Management 2 • Commence antidepressant • Multidisciplinary crisis intervention team • Moves to refuge • Staff offer support and monitoring • Community psychiatric nurse provides anxiety management

  28. Progress 1 • One month after index assault • Ex-partner charged • Very anxious re recrimination • Less distressed • Mood somewhat brighter • Continue same input

  29. Progress 2 • Three months after index assault • New housing identified • Talking of rebuilding life • No contact with ex-partner • Appropriate anxiety re recrimination • Wants to “deal with it” • Suitability for TFCBT reassessed

  30. Progress 3 • Six months after index assault • Situation remains more stable • Initial four sessions of TFCBT agreed • Keen to deal with index assault first • Gradual improvement over 20 sessions

  31. Key Issues • Trajectory • Readiness for treatment assessed • Pre-existing co-morbidity • Social issues • Single approach does not fit all

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