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

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

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 Julie Bradshaw , LCSW Clinical Research Investigator, Intermountain Healthcare 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….

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

Pediatric Anxiety and Trauma Treatment Brooks Keeshin , MD, Psychiatrist University of Utah Healthcare & Primary Children’s Hospital

Age of Onset for Anxiety Disorders 50% Physical Assault Exposure Beesdo et al. 2010; Finkelhoret al. 2009

Longitudinal Course of Pediatric Anxiety Syndromic threshold Incidence Birth t 1 t 2 Stability Birth t 1 t 2 Remission Birth t 1 t 2 Progression Birth t 1 t 2 Improvement Birth t 1 t 2 Assessments Adapted from Beesdo, Knappe and Pine. Psychiatr Clin N Am . 2009;32:483-524

Age of onset of PTSD After trauma Proximate to trauma or delayed Risk is compounded with multiple/chronic traumas

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

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

Key Treatment Points Trauma Anxiety • CBT is first line • CBT is first line o i.e. TFCBT o i.e. Coping Cat • No medications – although some • Sertraline, Fluoxetine and youth respond well to prazosin Duloxetine have greatest for nightmares evidence in adolescents o Don’t add drugs o Don’t add drugs o No benzos/SGAs o No benzos/SGAs

Key Treatment Points Trauma Anxiety • Increased risk for suicide • Increased risk for suicide o DBT or IOP or higher o DBT or IOP or higher • Substance Use Disorder • Substance Use Disorder o Precipitate use o Precipitate use o Exacerbated by withdrawl o Exacerbated by withdrawl

Treatment of Chronic Adult Anxiety and Trauma Julie Goudie- Nice , PhD, Psychologist Intermountain Healthcare

Objectives • Identify common challenges in treatment of 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

Adult Anxiety Pharmacotherapy Ky Dorsey , MD, Psychiatrist Intermountain Healthcare

Pharmacotherapy for Anxiety When to Treat Anxiety with Medications: Medications • Long-term vs. Short-term • Understand the Function of • Anti-depressants vs. Sedatives Anxiety • What is the Patient’s Functionality? o ADL’s o Ability to participate in therapy

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 with Alcohol Leads To… *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

Discussion Questions 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?