Case Study

1. Case Study • 7th grade boy presents for treatment. Client has been referred due to oppositional behaviors, ditching school, fighting, and failing grades.

2. Post Traumatic Stress Disorder LaMarr D. Edgerson MA, LMFT, CHt Trauma Specialist

3. Post Traumatic Stress Disorder Anatomy Memory Trauma

4. War Terrorism Physical Assault Sexual Assault Being teased? Embarrassing Moments Natural Disaster Death of loved one Domestic Violence Child Abuse Witness of events Emotional Abuse Potentially Traumatic Events

5. Est 5.2 million Americans dx between 18-54yrs old (3.6%). 1 million Vietnam Vets affected. What about Iraq and Afghanistan ? 2x number of women affected vs men. Often co-exist with depression, alcohol or other substance, or other anxiety disorders. PTSD Stats

6. Maslow In what ways can a traumatic event(s) effect your life?

7. Basic Anatomy Our brain develops from back to front: primitive - executive functions arise in that order.

8. Lymbic System The oldest part of the brain: This system is most responsible for our flight or fight system. It includes structures involved in emotion, motivation and emotional association with memory. Hypothalamus Hippocampus Amygdala

9. Corpus Callosum Each hemisphere of the human brain is a conscious system in its own right, perceiving, thinking, remembering,reasoning, willing and emoting. If the two hemispheres are separated, each is able to produce its own consciousness. Split brain syndrome The left hand doesn’t know what the right hand is doing - literally Alien-hand syndrome

10. Major relay station that monitors and processes incoming info before it’s sent to the upper regions of the brain. Receives auditory, somatosensory and visual sensory signals Thalamus Not a part of the limbic system

11. Hypothalamus Regulates the autonomic nervous system via hormone production and release. Initiates feelings, actions and emotions such as hunger, thirst, rage & terror.Affects and regulates blood pressure, sexual arousal and the sleep/wake cycle.

12. Involved with recognizing new experiences and with learning and memory, especially short-term memory and information relating to recent events. Hippocampus

13. Amygdala Stores emotional parts of memory, especially powerful feelings; also concerned with emotions such as anger and jealousy, and drives such as hunger, thirst and sexual desire. Sends msg to hypothalamus for activation of sympathetic nervous system: increase reflexes, facial expression of fear, activate dopamine, epinephrine and norepinephrine.

14. Importance of the fear center Fight or Flight

15. Memory What were you doing when this incident occurred?

16. Memory Input From Senses  Sensory Memory  Attention Not Paid   Attention Paid Information Lost    Short-Term Memory Memories Not Consolidated  Memory Consolidated  Long-Term Memory

17. Memory trace Short Term Memory • Also known as working memory • Used to manipulate info (mental mapping for directions) • Used to store small amounts for short periods (30-45 sec) • Quickly disappears by default - unless needed

18. Long Term Memory • Structure: Hippocampus • Anything from one minute - lifetime • Needs to be encoded (associated in a meaningful way) • Associated in a meaningful way • Consolidated and stored (permanent neuron change) • Believed to occur during dreaming (REM sleep)

19. Hebb’s Axiom • From the beginning of life, the brain responds to experience with the establishment of connections among neurons. Those pathways activated simultaneously become associated with one another and are more likely to be activated together again in the future.

20. Dreaming Why do we dream?

21. Dreaming REM sleep is crucial for memory consolidation and has been suggested to facilitate long-term potentiation allowing the strengthening of synaptic connections. Daniel Siegel

22. Trauma

23. Children & Trauma Pre-School • Cognitive: shorter attention span, confusion regarding event, location sequencing. • Physical: loss of appetite, overeating, bowel/bladder problems, sleep disturbance. • Emotional: generalized fear, nervousness, anxiety, irritability, fearful of reminders. • Behavioral: bed wetting, thumb sucking, nightmares, repetitive play, anxious attachment, clinging, aggression, disobedience.

24. Children & Trauma 3rd - 5th Grade • Preoccupation with their own actions during the event, specific fears, retelling and replaying the event, impaired concentration and learning, sleep disturbance, concerns about safety(theirs & others), inconsistent bx, somatic complaints, confusion, fearful, concerns for other victims and their family, close monitoring of parent response & recovery.

25. Children & Trauma Adolescents • Detachment, shame, guilt, self consciousness about their fear, vulnerability & other emotional responses, acting out, need for revenge, radical change in world views, life threatening reenactment

26. Children & Trauma Thoughts • Can a traumatic childhood result in learning disabilities? Studies in Beirut confirm that traumatized adolescents with PTSD, as compared to non-traumatized adolescent lagged behind in academic achievement.

27. Lasting Effects Trauma doesn’t just affect the person who was exposed. It also affects all the people with whom that person interacts. The more dependent a person is on a trauma survivor, the more deeply he or she will be affected.

28. Post-traumatic Stress Disorder

29. Post-traumatic Stress Disorder Defined • Re-experiencing distressing images, unwanted memories, nightmares or flashbacks & physical symptoms. • Avoidance of reminders of the event, including people, places or things. • Hyperarousal, reflected in physiological symptoms: insomnia, irritability, impaired concentration, hypervigilience and increased startle response.

30. Post-traumatic Stress Disorder Evidenced-Based • PET Scans reveal that Vets with PTSD show increased right amygdala activity when exposed to combat movies. • MRI studies show that both male combat vets and women survivors of childhood sexual abuse have shrunken hippocampal volumes.

31. Therapy

32. Cognitive Behavior Therapy Cognitive Restructuring • CBT helps the client first identify the traumatic memory - evaluate their validity, challenge defeating or destructive thoughts, then replace them with a healthy emotional state.

33. Reframing Cognitive Behavior Therapy Cognitive Restructuring • Benefit: Allows integration of trauma memory into conscious memory; associated thoughts are altered to reflect current life space & memories can become manageable (to an extent). Stops dysfunctional thoughts Victim to survivor thinking

34. Mind/Body Connection Trauma is experienced at a sensory level and stored as an implicit memory. Implicit memory (sensations of trauma) must be linked with explicit memory (facts or reality of incident) in order for the victim to be able to reorder the experience in a way that is manageable. William Steele, PhD

35. Exposure Therapy • Derived from the learning theory. • Fear is maintained through operant conditioning & the effort to avoid or escape these responses. • Avoidance supports the fear

36. Exposure Therapy • In order modify the trauma - the memory must be fully reactivated. • The client’s ability to decrease fear or anxiety is dependent on the “controlled” reliving of that fear in a safe environment. • The client is helped to form a new narrative that places the traumatic memory in the past as opposed to the here and now.

37. Art Therapy Play Therapy Stress Inoculation Systematic Desensitization Virtual Reality EMDR Emotional Focused Therapy Tapas Acupressure Therapy Exposure Therapy

38. Avoidance **Disassociation** Increased drug & alcohol usage Secondary Gain Blocking Flooding Challenges with trauma work

39. Patience Think outside the box Consider client factors Stressors Health Relationships Finances Only speak when necessary Cognitive interweave Follow the client It’s the client’s therapy Don’t push Lessons I have learned

40. A: assess for risk (self harm) L: listen non-judgmentally G: give reassurance and info. E: encourage professional help E: encourage self care Action Plan

41. The End Post Traumatic Stress Disorder LaMarr D. Edgerson MA, LMFT, CHt Trauma Specialist