The European Network for Traumatic Stress Training & Practice

Assessment, formulation and treatment planning for psychologically traumatised individuals

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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