Empowering Families Dealing with Anxiety & Trauma: Navigating - - PowerPoint PPT Presentation

MODERATOR: Brooks Keeshin, MD, Psychiatrist, University of Utah Healthcare & Primary Children’s Hospital PRESENTERS: Julie Bradshaw, LCSW, Clinical Research Investigator, Intermountain Healthcare Julie Goudie- Nice, PhD, Psychologist, Intermountain Healthcare Ky Dorsey, MD, Psychiatrist, Intermountain Healthcare

Empowering Families Dealing with Anxiety & Trauma: Navigating & Advocating for the Right First Steps

Objectives

• Identify strategies to empower patients and

families as leaders in achieving their health goals

• Understand the patient experience as it

applies to trauma and anxiety

• Identify commonalities in trauma informed

care and family centered care

The Traumatic Stress Patient Experience

A teenager goes to a party and the next memory she has is the emergency department and doctors who don’t know what to do with her. So she waits….

Julie Bradshaw, LCSW Clinical Research Investigator, Intermountain Healthcare

Why Does it Matter?

Family Centered/Trauma Informed Care

Evidenced-Informed Practice

• 1. Pose a Question
• 2. Search for Evidence
• 3. Critically appraise the evidence
• 4. Select treatment with the client
• 5. Evaluate client outcomes

Key Components of Evidenced Based Practice for Trauma

• Building a strong therapeutic

relationship

• Parent Support, conjoint therapy, or

parent training

• Providing psychoeducation to children

and caregivers

• Re-establishing a sense of physical and

psychological safety

• Emotional expression and regulation

skills

Key Components of Evidenced Based Practice for Trauma

• Anxiety management and relaxation

skills

• Cognitive processing or reframing
• Exposure to traumatic memories and

feelings in tolerable doses so that they can be mastered and integrated

• Personal safety training and

empowerment activities

• Resilience and closure

Brooks Keeshin, MD, Psychiatrist University of Utah Healthcare & Primary Children’s Hospital

Pediatric Anxiety and Trauma Treatment

Age of Onset for Anxiety Disorders

Beesdo et al. 2010; Finkelhoret al. 2009

50% Physical Assault Exposure

Longitudinal Course of Pediatric Anxiety

Adapted from Beesdo, Knappe and Pine. Psychiatr Clin N Am. 2009;32:483-524

Birth t1 t2 Remission Progression Birth t1 t2 Improvement Assessments Birth t1 t2 Incidence Stability Birth t1 t2 Birth t1 t2 Syndromic threshold

Age of onset of PTSD

After trauma Proximate to trauma or delayed Risk is compounded with multiple/chronic traumas

Good Poor Level of adaptation Pre-trauma Peri-trauma Post-trauma Adapted from Layne et al., 2009

Time Course of Trauma

Screens for Traumatic Stress and Anxiety

PTSD Trauma Symptom Checklist for Children (TSCC) Trauma Symptom Checklist for Young Children (TSCYC) CPSS UCLA PTSD RI* Anxiety PARS SCARED GAD-7

Key Treatment Points

Trauma

• CBT is first line
• i.e. TFCBT
• No medications – although some

youth respond well to prazosin for nightmares

• Don’t add drugs
• No benzos/SGAs

Anxiety

• CBT is first line
• i.e. Coping Cat
• Sertraline, Fluoxetine and

Duloxetine have greatest evidence in adolescents

• Don’t add drugs
• No benzos/SGAs

Key Treatment Points

Trauma

• Increased risk for suicide
• DBT or IOP or higher
• Substance Use Disorder
• Precipitate use
• Exacerbated by withdrawl

Anxiety

• Increased risk for suicide
• DBT or IOP or higher
• Substance Use Disorder
• Precipitate use
• Exacerbated by withdrawl

Julie Goudie- Nice, PhD, Psychologist Intermountain Healthcare

Treatment of Chronic Adult Anxiety and Trauma

Objectives

• Identify common challenges in treatment
• f long-term/chronic anxiety
• Identify potential solutions to those

challenges

• Create starting points for collaborative

discussion to improve patient care

What is “Chronic” Anxiety

Anxiety that:

• Lasts longer than 6-12 months
• Impairs one or more areas of patient functioning
• OCD, Panic, GAD, PTSD

Challenges in Treating Chronic Anxiety

Differences between patient goals and provider goals

• Anxiety “free” versus anxiety management
• Criteria for “success” (resurgence of anxiety often viewed as

personal failure or failure of treatment)

• Difficulties in establishing what is “normal”

Challenges in Treating Chronic Anxiety (continued)

Limitations of current available tools and treatments

• Medications and their role in therapy
• Long-term anxiety management options are limited

What works?

Empirically-supported treatments

• Cognitive Behavioral Therapy (Modini and Abbott, 2016)
• Psychodynamic approaches (Leichsenring, et al., 2014)
• Medication management
• Mindfulness-Based Stress Reduction (Serpa, et al., 2014)
• EMDR (Shapiro, 1999)
• Prolonged Exposure (McLean & Foa, 2013)

What works? (continued)

Empirically-supported treatments

• Exercise, diet changes
• Sleep hygiene
• Psychoeducation

Limitations of Empirically-Supported Treatment

What gets researched

• Easy to “manualize”
• Easy (or easier) to be time-limited

Who is studied

• Often “neat” anxiety (no co-occurring disorders)
• Limited to some cultural factors

Lack of long-term followup

• Followup of most studies limited to 6 months or less

Starting the conversation

Empowering patients

• Ask questions- What can I expect from therapy? Do I have to talk about

the trauma?

• Learn how medication use can impact therapy
• Address options (therapeutic approach and MHI vs. outpatient)
• Warm hand-offs

Collaborating with providers

• Check-in about patient’s progress-Message Center or in person
• Discuss concerns

Ky Dorsey, MD, Psychiatrist Intermountain Healthcare

Adult Anxiety Pharmacotherapy

Pharmacotherapy for Anxiety

When to Treat Anxiety with Medications

• Understand the Function of

Anxiety

• What is the Patient’s

Functionality?

• ADL’s
• Ability to participate in therapy

Medications:

• Long-term vs. Short-term
• Anti-depressants vs. Sedatives

Short-Term Treatment of Anxiety

SleepAlertnessAnxiety

• ALL Short-term anxiolytics work through

their sedative properties

• Anti-histamines
• Gabapentin
• Neuroleptics

Which Leads Me to… Treating Anxiety with Benzodiazepines

The “Opiates of Anxiety”

• Mechanism of Action (Think Alcohol)
• Xanax vs. Long Acting
• Risks of Benzodiazepine Use – Anxiety,

Depression, Delirium, Falls, Disinhibition…

• Indications for use
• Please don’t take this picture seriously.
• Seriously. It’s a terrible idea.

*Treating anxiety complicated by substance misuse Anne Lingford-Hughes, John Potokar, David Nutt Advances in Psychiatric Treatment Mar 2002, 8 (2) 107-116; DOI: 10.1192/apt.8.2.107

Treating Anxiety with Alcohol Leads To…

Panel Question 1

• How can a team-based care approach between providers improve

the treatment process for patients with anxiety and trauma?

• How can providers come together better to adhere to anxiety and

trauma best practice?

Discussion Questions