Posttraumatic Stress Disorder

Chapter Seven

Background of PTSDPsychic trauma is the result of experiencing

an acute overwhelming threat in which disequilibrium occurs.

Most people are extremely resilient and will quickly return to a state of mental and physical homeostasis.

Acute stress disorder is when symptoms continue for a period of 2 days to 1 month and have an onset within 1 month of the traumatic event.

Background Cont. If acute stress disorder symptoms develop,

they will typically diminish in 1 to 3 months.

Delayed PTSD is when symptoms disappear for a period of time and then reemerge in a variety of symptomatic forms months or years after the event.

Benchmarks Railway train accidents

“Railway spine”

Freud’s research on trauma cases of young Victorian women

“Hysterical neurosis”

Traumatized combat veterans (especially veterans of the Vietnam Conflict)

“Shell shock”“Combat fatigue”

Benchmarks Cont.Recognition of domestic violence and rape

via the women’s movement“Battered women’s syndrome”

All came together to be defined as posttraumatic stress disorder in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (1980).

Diagnostic CriteriaExposure to a trauma that involves:

Actual or perceived threat of serious injury or death to self or others

Response to the trauma was intense fear, helplessness, or horror

Symptoms arise that were not evident before the event

Persistent re-experiencing of the trauma in at least ONE of the following ways:

Recurrent and distressing recollections Recurrent nightmares Flashback episodes Distress related to internal or external cues that symbolize

the event Physiological reactions to events that symbolize the trauma

Diagnostic Criteria Cont. Behaviors consistent with at least THREE of

the following: Persistently avoiding related thoughts, dialogues, or

feelings Persistently avoiding related activities, people, or

situations Inability to recall important details of the trauma Markedly diminished interest in significant

activities Emotionally detached from others Restricted range of affect Sense of foreshortened future

Diagnostic Criteria Cont.Persistent symptoms of increased nervous system

arousal that were not present prior to the trauma, as indicated by at least TWO of the following:

Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hyper-vigilance Exaggerated startle reactions to minimal stimuli

The disturbance causes clinically significant impairment in social, occupational, or other critical areas of living.

PTSD in ChildrenBus kidnapping in Chowchilla, CA

30-50% of children will experience at least one traumatic event by the age of 18.

3-16% of boys and 1-6% of girls will develop PTSD.

The type of trauma will impact the likelihood of developing PTSD.

Nearly 100% if they see a parent killed or sexually assaulted.

Approximately 90% if the child is sexually assaulted. 77% if the child witnesses a school shooting. 35% if the child witnesses violence in their

neighborhood.

Diagnostic Criteria for ChildrenMust experience disorganized or agitated

behavior

May demonstrate regressive behaviors

May relive the trauma through repetitive play

Generalized nightmares (i.e., monsters)

May believe that they can see into the future

Somatic complaints of headaches and stomachaches

Types of TraumaType I Trauma

Sudden and distinct traumatic experience

Type II Trauma (aka “complex PTSD”)Persistent and derives from repeated

traumatic eventsHas three cardinal symptoms:

Somatization (Physical ailments)Dissociation (Divisions of personality)Affect dysregulation (Changes in impulse

control, attention, perception, and significant relationships)

Incidence, Impact, and Trauma TypeIncidence

Approximately 20% of people will experience a trauma Higher in adolescents, employees of hazardous

occupations, victims of severe burns and sexual assault, refugees, and combat veterans

Residual Impact Can happen even when someone has excellent coping

skills and a positive support system Example of Chris (veteran of the U.S. Marine Corps

who served in the Vietnam Conflict)

Importance of Trauma Type Marked distinction between natural and human-made

catastrophes

Vietnam, The ArchetypeHyper-vigilance

Lack of goals

Individual/Individualizer

Bonding, debriefing, and guilt

Civilian adjustment

Substance abuse

Attitude

Antiwar sentiment

10 Predisposing Variables of PTSD Degree of threat

Degree of bereavement

Speed of onset

Duration of the trauma

Degree of displacement in home continuity

Potential for recurrence

Degree of exposure to death and destruction

Degree of moral conflict inherent in the situation

Role of the person in the trauma

Proportion of the community affected

Symptoms of PTSDIntrusive-repetitive ideation

Visual images triggered by sights, sounds, smells, or tactile cues

Denial/numbing Emotions of guilt, sadness, anger, and rage

Increased nervous symptom arousal Acoustic startle response

Dissociation Possibly the most important long-term predictive variable for

PTSD and is connected to “complex PTSD”

Family responses Possible discrepancy of reaction based on the type of trauma May “turn on” the victim if they can not deal with the trauma

Maladaptive Patterns Characteristic of PTSDDeath imprint

Clear vision of one’s own death in concrete terms

Survivor’s guilt Guilt over surviving, not preventing another’s death, not

having been braver, or complaining when other’s have suffered more

Desensitization Contradictory emotions within the person may lead to

hostile, defensive, anxious, or depressive states

Estrangement Feelings that any future relationships will be insignificant in

the greater scheme of things

Emotional enmeshment Continuous struggle to progress (emotional fixation)

Impact of Iraq and AfghanistanComprehensive Soldier Fitness Program

Integrated, proactive approach to developing psychological resilience in soldiers, family members, and the Army’s civilian workforce.

Components: The Global Assessment Tool Master Resilience Trainer course Family skills component

Treatment of AdultsAssessment

Structured interview Self-reports Empirically derived scales Overview of assessment

Phases of recovery Emergency/outcry Emotional numbing/denial Intrusive-repetitive Reflective-transition Integration

Treatment of Adults Cont.Initiating intervention

Victims may refuse early intervention It is too difficult to talk about the trauma They believe that people of good character should

be able to cope with traumatic events.

Importance of acceptance Disclosure is difficult because the events of the

trauma may seem horrifying and socially unacceptable.

Treatment of Adults Cont.Risks of treatment

No magical cures Intensity of treatment may impact occupations or relationships May get worse before you get better Re-experiencing the traumatic event is very painful Difficult to give up thoughts of revenge related to the trauma Pain associated with accepting the world as it is Difficult to accept one’s own limitations

Multiphasic/multimodal treatment Eclectic Therapy

Behavioral, cognitive-behavioral, humanistic, emotion-focused

Psychotropic medication No fixed pharmaceutical regimen; results vary per the

individual

Eye Movement Desensitization and Reprocessing (EMDR)

Basic technique is to have the client visualize the trauma or experience thoughts and feelings related to the trauma while watching the therapist’s finger as it moves rapidly back and forth in front of the client’s face.

Controversial

Is effective with some people and is not intrusive

EMDR Cont.History Taking and Treatment Planning

Preparation

Assessment

Desensitization

Installation

Body Scan

Closure

Reevaluation