Posttraumatic Stress Disorder (PTSD): An overview

1. By: Kryn Palmquist Posttraumatic StressDisorder(PTSD):An overview

2. Introduction: • DSM IV- criterion /testing • Symptoms • Feelings: Anger • Suicide: Mexico, Canada, and The United States • Correlation with trauma and health • Positives-moving forward

3. DSM-IV-Criterion • A. The person has been exposed to a traumatic event in which both of the following were present: • The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. • The person’s response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganized or agitated behavior.

4. DSM-IV-Criterion • B. The traumatic event is persistently re-experienced in one (or more) of the following ways: • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. • Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashbacks episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

5. B. Continued: 4. Intense psychological distress at exposure to internal or external cause that symbolize or resemble an aspect of the traumatic event. 5. Psychosocial reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

6. DSM-IV-Criterion • C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: • Efforts to avoid thoughts, feelings, or conversations associated with the trauma. • Efforts to avoid activities, places, or people that arouse recollections of the trauma. • Inability to recall an important aspect of the trauma. • Markedly diminished interest or participation in significant activities

7. C. Continued: 5. Feeling of detachment or estrangement from others 6. Restricted range of affect (e.g., unable to have loving feelings) 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

8. DSM-IV-Criterion • D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hyper-vigilance • Exaggerated startle response

9. DSM-IV-Criterion • E. Duration of the disturbance (symptoms in Criteria B,C, and D) is more than 1 month. • F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Acute: if duration of symptoms is less than 3 months • Chronic: if duration of symptoms is 3 months or more. • With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

10. Why does this happen? • Flight vs. Fight • Mowrer’s Two Factor Theory • Classical Conditioning

11. Testing • UCLA PTSD Index • Child version • Parent version • Adolescence version • Adult Version-similar

12. Symptoms3 PTSD Symptom Clusters • Re-experiencing: re-living the traumatic event • Numbing: restricted range of affect, feeling of detachment or estrangement from others • Avoidance: efforts to avoid thoughts about trauma • Arousal Symptoms: feelings of anger and anxiety

13. Symptoms • Anxiety • Depression • Intrusive thoughts & images from the assault/ traumatic event • Sleep disturbances: Nightmares & Insomnia

14. Anger/Other symptoms of PTSD • Fear, helplessness, horror, and strong feelings of anger-possible feelings following a traumatic event • Arousal symptoms: irritability and outbursts of anger • Increasing number of studies have shown increased anger following a traumatic event is strongly correlated with the severity of PTSD

15. Anger/Other symptoms of PTSD • Correlation of anger with a traumatic event is significantly higher with increasing time since the event-ex. Military war experience • In some studies, anger predicted PTSD severity at subsequent assessments, however it did the opposite in other studies.

16. Theories of Anger & PTSD • Riggs et al.: people with PTSD are motivated to avoid feelings of fear and that anger serves as a welcome distracter from fear-eliciting traumatic memories. • Cognitive models: PTSD severity is correlated with rumination about the traumatic event and its consequences. • Example • Increases depressive affect & angry affect

17. Mexico City AdolescencesSuicide • Traumatic events: common • Profound distress-> psychiatric disorders, PTSD, and depression • Traumatic events in childhood have been linked to suicide, attempts, and ideation • Large increase in the past 2 decades of youth committing suicide in Mexico • One of the greatest among 28 countries • Why?-large city= economic hardships, increased drug trafficking, population density, fewer regulations/less enforcement of safety and traffic issues

18. Mexico City AdolescencesSuicide • How is this all related? • Traumatic events have been shown to increase the probability of psychiatric disorders • Psychiatric disorders increase the probability of suicide • Studies have shown that Mexican adolescents who have suffered a traumatic event during their childhood are at an increased risk for suicidal ideation, making a suicide plan, and for suicide attempts

19. Canadian/U.S. Military Personnel Suicide • Mental health issues have been increasing in the past few years • Suicide is the second most common cause of death for US Military • Veterans are more than twice as likely to die by suicide compared to the general population

20. Canadian/U.S. Military Personnel Suicide • Risk Factors: • Traumatic events- 38% suicidal ideation • Military personnel are exposed to high rates of trauma during combat and peacekeeping missions • Predisposing Factors: • Childhood traumas • Pre-military traumas

21. Health + Trauma = ? • Researchers have found strong associations between childhood trauma and poor physical and mental health • PTSD seems to be the cause of the health problems • PTSD is more common in women than in men (sexual abuse, emotional abuse etc.)

22. PTSD and Growth:Moving Forward • Trauma doesn’t always = PTSD • Can develop positive changes in life • Greater appreciation for life • Posttraumatic growth • Sense of survival

23. PTSD and GrowthMoving Forward • What can we do as counselors? • Begin with a thorough evaluation • Sessions: weekly treatment sessions 90 minutes long • Suggested Guidelines: • Adopt a nonjudgmental attitude • Display a comfortable attitude when the client describes their traumatic experience • Demonstrate knowledge of PTSD • Express confidence in the treatment program • Highlight the client’s personal resources and praise them for having the courage to work on their problems • Normalize the client’s response to the traumatic event

24. For more information: • Treating the Trauma of Rape, Cognitive-Behavior Therapy for PTSD by: Edna B. Foa

25. Questions?

26. White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force Complex trauma in children and adolescents

27. What is Complex Trauma? • Complex trauma- the dual problem of children’s exposure to traumatic events and the impact of this exposure on immediate and long-term outcomes. • Refers to children’s experiences of multiple traumatic events that occur within the caregiving system- the social environment that is supposed to be the source of safety and stability in a child’s life.

28. What is Complex Trauma? • Exposure to traumatic stress in early life is associated with enduring sequelae that not only incorporate, but also extend beyond, Posttraumatic Stress Disorder (PTSD).

29. These sequelae span multiple domains of impairment and include: • Self-regulatory, attachment, anxiety, and affective disorders in infancy and childhood • Addictions, aggression, social helplessness and eating disorders • Dissociative somataform, cardiovascular, metabolic, and immunological disorders • Sexual disorders in adolescence and adulthood • Re-victimization

30. Diagnostic Issues for Complex Trauma: Common Diagnosis • ADHD • ODD • Conduct Disorder • Generalized Anxiety Disorder • Separation Anxiety Disorder • Reactive Attachment disorder • Each of these diagnoses captures an aspect of the traumatized child’s experience, but frequently does not represent the whole picture. As a result, treatment often focuses on the particular behavior identified, rather than on the core deficits that underlie the presentation of complexly traumatized children.

31. 7 Domains of Impairment in Children Exposed to Complex Trauma • Attachment • Uncertainty about the reliability and predictability of the world • Problems with boundaries • Distrust and suspiciousness • Social isolation • Interpersonal difficulties • Difficulty attuning to other people’s emotional states • Difficulty with perspective taking • Difficulty enlisting other people as allies 2. Biology • Sensor motor development problems • Hypersensitivity to physical contact • Analgesia • Problems with coordination, balance, body tone • Difficulties localizing skin contact • Somatization • Increased medical problems across a wide span, e.g. pelvic pain, asthma, skin problems, autoimmune disorders, pseudo seizures

32. 7 Domains Continued 3. Affect Regulation • Difficulty with emotional self-regulation • Difficulty describing feelings and internal experience • Problems knowing and describing internal states • Difficulty communicating wishes and desires 4. Dissociation • Distinct alterations in states of consciousness • Amnesia • Depersonalization and de-realization • Two or more distinct states of consciousness, with impaired memory for state-based events

33. 7 Domains Continued 5. Behavioral Control • Poor modulation of impulses • Self-destructive behavior • Aggression against others • Pathological self-soothing behaviors • Sleep disturbances • Eating disorders • Substance abuse • Excessive compliance • Oppositional behavior • Difficulty understanding and complying with rules • Communication of traumatic past by reenactment in day-today behavior or play (sexual, aggressive, etc.) 6. Self-Concept • Lack of a continuous, predictable sense of self • Poor sense of separateness • Disturbances of body image • Low self-esteem • Shame and guilt

34. 7 Domains Continued 7. Cognition • Difficulties in attention regulation and executive functioning • Lack of sustained curiosity • Problems with processing novel information • Problems focusing on and completing tasks • Problems with object constancy • Difficulty planning and anticipating • Problems understanding own contribution to what happens to them • Learning difficulties • Problems with language development • Problems with orientation in time and space • Acoustic and visual perceptual problems • Impaired comprehension of complex visual-spatial patterns

35. A Closer Look- Attachment • The early caregiving relationship provides a relational context in which children develop their earliest models of self, other, and self in relation to others. • This attachment relationship also provides the scaffolding for the growth of many developmental competencies.

36. Attachment • A secure attachment pattern, present in approximately 55-65% of the normative population, is thought to be the result of receptive, sensitive caregiving. • Insecure attachment patterns have been consistently documented in over 80% of maltreated children. These failures to create a secure dyadic relationship may leave an environment of vulnerability which may allow for the occurrence of complex trauma exposure.

37. Attachment with insecure patterns: • Avoidant- associated with predictably rejecting caregiving • Ambivalent-when children experience patents alternating between validation and invalidation in a predictable manner • Disorganized-when co-regulation is not provided or results in aversive consequences early in life, this child is at risk for a complex and severe type of disruption of all the core biopsychosocial competencies

38. Attachment • Children living with unpredictable violence and repeated abandonment often fail to develop appropriate language and verbal processing abilities. • They then cope with threatening events and feelings of helplessness by restricting their processing of what is happening around them.

39. Attachment • Disorganized attachment has been hypothesized to interfere with the development of neural connections in critical brain areas (e.g. the left and right hemispheres of the orbital prefrontal cortex and their connective pathways)

40. Biology • Neurobiological development follows genetically “hard-wired” programs that are modified by external stimuli. • During the first few months after birth, only the brainstem and midbrain are sufficiently developed to sustain and alter basic bodily functions and alertness.

41. Biology • In toddlerhood and early childhood, the brain actively develops areas responsible for: • Filtering sensory input to identify useful information • Learning to detect (amygdala) and respond defensively (insula) to potential threats • Recognizing information or environmental stimuli that comprise meaningful contexts • Coordinating rapid goal-directed responses

42. Biology • Trauma interferes with the integration of left and right hemisphere brain functioning, which explains traumatized children’s “irrational” ways of behaving under stress. • In early childhood, biologically compromised children are at risk for disorders in reality orientation (autism), learning (dyslexia), or cognitive and behavioral self-management (ADHD)

43. Biology • In middle childhood and adolescence, the most rapidly developing brain areas are those responsible for three core features of “executive functioning” necessary for autonomous functioning and engagement in relationships. • Conscious self awareness • Ability to assess the valence and meaning of complex emotional experiences • Ability to determine a course of action based on learning from past experiences and creation of an inner frame of reference informed by accurate understanding of other persons’ different perspectives

44. Affect Regulation • Deficits in the capacity to regulate emotional experience may be broadly classified in three categories: • Deficits in the capacity to identify internal emotional experience • Difficulties with the safe expression of emotions • Impaired capacity to modulate emotional experience

45. Affect Regulation • Following the identification of emotional state, a child must be able to express emotions safely, and then modulate or regulate internal experience. Complexly traumatized children show impairment in both of these skills. Distortions of emotional expression in traumatized children have been observed to range across a full spectrum, from overly constricted or rigid to excessively labile and explosive.

46. Affect Regulation • Over time, traumatized children are vulnerable to the development and maintenance of disorders associated with chronic dysregulation of affective experience, including disorders of mood. The prevalence of Major Depression among individuals who have experienced early childhood trauma is an example of the lifelong impact complex trauma may exert over regulator capacities.

47. Affect Regulation • Childhood trauma appears not only to increase risk for Major Depression, but also to alter the course of illness in ways that contribute to a poorer prognosis. A history of childhood trauma seems to predispose toward earlier onset of affective problems, which in turn is associated with more depressive episodes and poorer outcome.

48. Dissociation • Key feature • “Failure to integrate or associate information and experience in a normally expectable fashion.” (Putnam, 1997, p.7) • Runs along a continuum from normal kinds of experiences such as getting lost in thought while driving, to peritraumatic dissociation during traumatic exposures, to dissociative disorders

49. Dissociation • Linked to several biological markers through the correlation of the Dissociative Experiences Scale to decreased left hippocampal volume in women.

50. Behavioral Regulation • Chronic childhood trauma is associated with both under and over controlled behavior patterns • Over control-strategy that may counteract the feelings of helplessness and lack of power that are often a daily struggle for chronically traumatized children. • Abused children demonstrate rigidly controlled behavior patterns, such as compulsive compliance with adult requests, as early as the second year of life. • Many traumatized children are very resistant to changes in routine and display rigid behavioral patterns, including inflexible bathroom rituals and eating problems.