1. Dr Michelle Sowden Consultant Clinical Psychologist SABP

2. Focus for today What is psychological trauma and why does it matter in this context? Prevention Promoting recovery Psychological treatment of psychological trauma

3. What is psychological trauma? Re-experiencing of the event as if it were happening now Disturbing emotions Disturbing physical sensations Unhelpful beliefs Uncontrollable behaviours (escape, protect, avoid) Loss of sense of self, who I am, what my life is about

4. Psychological trauma in critical illness Exposure to frightening or disorienting experiences Impaired ability to process and make sense of events Medication (sedation) Disorientation Environment Sleep deprivation Pain Delirium

5. Events leading up to admission Events during the admission Significant risk of developing psychological trauma. 14–27% of ICU survivors develop symptoms of psychological trauma.

6. Case example Metropolitan police officer Admitted with necrotising fasciitis Delirious on the unit – range of fantasies including being on the wires in WWII Afterwards difficulty making sense of events, vague, disturbing memories and dreams Avoidance of underground / supermarket shopping Loss of sense of self

7. Impact on recovery Impairs quality of life Impairs ability to take up the reins of life again Work, hobbies, childcare etc. Impacts ability to engage in healthcare / rehab. Undermines future health directly and indirectly

9. Memory formation during traumatic events Brain function affected by heighted arousal Focus on survival in the moment Lack of integration with existing memory networks or related experiences Memories are laid down as sensory memories of how it looked, felt, sounded like etc

10. Processed memories are stored in networks - images, thoughts and sensations are linked /cohesive

11. Unprocessed memories are stored in separate, unconnected networks with event related cognitions, emotions and sensations

12. Processed memories Work to retrieve memory of specific events Well discriminated triggers e.g. On the wires in WWII triggered by watching a film in which someone describes being on the wire in a war

13. Unprocessed memories Easily triggered Cues include similar sensory experiences – pain, temperature, pressure, sounds etc e.g. Memory of being on the wires in WWII triggered by pain anywhere in the body

14. Psychological recovery Make sense of the event Transform sensory memories to a narrative /autobiographical memories Challenge unhelpful beliefs about ourselves

16. What blocks recovery Heightened arousal Sensory memory Heightened arousal impairs processing

17. Avoidance The solution becomes the problem Cognitive avoidance blocks processing Behavioural avoidance blocks learning

18. Insufficient data to enable elaboration into a logical sequence Vague memories Gaps in memory Memory that lack ecological validity - WWII

19. Illness related factors Pain Sleep deprivation Medication Restricted function

20. Natural recovery The brain is geared to recover Adaptive information processing What can I learn from this? Converting psychological trauma to a resource for the future

21. What you can do to help Prevention Orientate to reality Early identification and management of delirium Manage the environment Identify and manage anxiety Give information as requested

22. Promoting recovery Offer access to information Patient Diary Return visit to ICU

23. Managing ICU visits - anxiety reduction Remain on the ICU until anxiety reduces

24. Closing moments of an event colour perception Closing moments of an event colour our judgement of the whole event Work done with endoscopy Try and ensure patient leaves when coping well

25. Psychological Intervention for psychological trauma NICE Guidance CG26 For trauma < 3months post event Trauma focused Cognitive behavioural therapy For trauma > 3 months post event also consider EMDR 8 to 12 sessions between 60 to 90 minutes

26. Preparing a patient for a referral Distinguish between psychological intervention and counselling Hard work, active approach Temporary exacerbation of symptoms Consider timing May be delayed onset – 2 to 4 months post event

27. EMDR Eye Movement Desensitisation and Reprocessing Therapy Treatment of choice for single events trauma Faster than CBT by about 40% - cost effective and time limited distress for patients New protocols for immediate aftermath of traumatic events (R-TEP)

28. Intervention Facilitate conversion of sensory memories to autobiographical Reliving the experience to enable processing Activate the memory through identifying image, cognition, emotion and physical sensation Work with that reaction until distress subsides Continue until new learning takes place “I’m safe now”

29. Likely to be distressing Manage avoidance Enable re-engagement with life

30. Where to refer IAPT In-house Psychiatric Liaison Services Flag up to existing mental health services Limited resources

31. Not everyone can benefit Dissociation - may be harmful May need stabilising first Inability to tolerate distress Other life events Concurrent metal health problems

32. Summary High prevalence of psychological trauma following critical care Preventative strategies are effective Psychological treatments are available for those who continue to struggle