PCCYFS 2012 Annual Spring Conference Advanced Trauma Interventions for Adolescent with Co-Occurring Mental Health Disorders Presented By: John P. Seasock

PCCYFS 2012 Annual Spring Conference

Advanced Trauma Advanced Trauma Interventions for Interventions for

Adolescent with Co-Adolescent with Co-Occurring Mental Health Occurring Mental Health

DisordersDisordersPresented By:

John P. Seasock LPC, PsyDSpecialist/Consultant

PCCYFS 2012 Annual Spring

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Presented by: John P. Seasock LPC, PsyD

Specialist/Consultant

Renaissance Psychological and Counseling Corporation

138 Sharpe StreetKingston, PA 18704

Phone: 570-237-5440Fax: 570-287-2256

[email protected]

R P C


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Incidence rates of trauma in children, adolescents, and adultsA few studies of the general population have been conducted that examine rates of exposure and PTSD in children and adolescents and adults. Results from these studies indicate:•15 to 43% of females and 14 to 43% of males have experienced at least one traumatic event in their lifetime. •Of those children, adolescents and adults who have experienced a trauma, 3 to 15% of females and 1 to 6% of males could be diagnosed with PTSD.•Rates of PTSD are much higher in children and adolescents recruited from at-risk samples. •The rates of PTSD in these at-risk children and adolescents vary from 3 to 100%.


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Identification of “traumatic experiences”• A diagnosis of PTSD means that an individual

experienced an event that involved a threat to one's own or another's life or physical integrity and that this person responded with intense fear, helplessness, or horror.

• Persons may be diagnosed with PTSD if they have survived natural and man made disasters such as floods; violent crimes such as kidnapping, rape, murder of a loved one, sniper fire, school shootings, motor vehicle accidents, plane crashes; severe burns; exposure to community violence; war; peer suicide, sexual and physical abuse and so on.


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Role of cognitions/beliefs in interpreting traumatic experiences• Because most trauma survivors don't know how

trauma usually affects people, they often have trouble understanding what is happening to them.

• They may think it is their fault that the trauma happened, that they are going crazy, or that there is something wrong with them because other people who were there don't seem to have the same problems.

• The interpretation and appraisal of the experienced trauma is the key to whether a person continues on to develop symptoms of PTSD or resolves any emotional conflict after a period of stress (acute).

• The complex disorder of PTSD is a disorder that begins with anxiety producing “thoughts”


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Reactions of children & adolescents to traumatic experiences

• The diagnosis of Posttraumatic Stress Disorder (PTSD) was formally recognized as a psychiatric diagnosis in 1980.

• At that time, little was known about what PTSD looked like in children and adolescents.

• Today, we know children and adolescents are susceptible to developing PTSD, and we know that PTSD has different age-specific features.

• We are beginning to develop child-focused interventions


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Distinctive Neurobiological and Physiological changes in traumatized individuals• PTSD results from several neurobiological and

physiological changes.• It is accompanied by neurobiological changes in

the central and autonomic nervous systems.• These changes may include altered brainwave

activity, decreased volume of the hippocampus and abnormal activation of the amygdala.

• These psycho-physiological alterations tend to lead to abnormal levels of key hormones involved in the body’s response to stress.

• People with PTSD generally have increased thyroid function, lower cortisol levels and higher norepinephrine and epinephrine levels.


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Risk Factors/Protective Factors

There are three factors that have been shown to increase the likelihood that children will develop PTSD. These factors include :•The severity of the traumatic event,•The parental reaction to the traumatic event, •The physical proximity to the traumatic event.


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There are several other factors that affect the occurrence and severity of PTSD: • Family support and parental coping have also

been shown to affect PTSD symptoms in children.

• Children and adolescents who are farther away from the traumatic event report less distress.

• Rape and assault are more likely to result in PTSD than other types of traumas.

• Additionally, if an individual has experienced a number of traumatic events in the past, those experiences increase the risk of developing PTSD.


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There are several other factors that affect the occurrence and severity of PTSD, cont.

• Several studies suggest that girls are more likely than boys to develop PTSD.

• While some studies find that minorities report higher levels of PTSD symptoms, researchers have shown that this is due to other factors such as differences in levels of exposure.


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There are several other factors that affect the occurrence and severity of PTSD, cont.

• It is not clear how a child’s age at the time of exposure to a traumatic event impacts the occurrence or severity of PTSD. Differences that do occur may be due to differences in the way PTSD is expressed in children and adolescents of different ages or developmental levels

• People who have PTSD also have strengths, interests, commitments, relationships with others, past experiences that were not traumatic, desires, and hopes for the future.


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Diagnostic Criteria for Acute Stress Disorder (DSM-IV-TR)

A. The person has been exposed to a traumatic event in which both of the following were present:1. 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

2. The person’s response involved intense fear, helplessness, or horror


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Diagnostic Criteria for ASD (DSM-IV-TR), cont.

B. Either while experiencing or after experiencing the distressing event, the individual has three or more) of the following dissociative symptoms:1. A subjective sense of numbing,

detachment, or absence of emotional responsiveness

2. A reduction in awareness of his or her surroundings (e.g., “being in a daze”)

3. Derealization4. Depersonalization5. Dissociative amnesia (i.e., inability to

recall an important aspect of the trauma


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Diagnostic Criteria for ASD(DSM-IV-TR), cont.

C. The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience: or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people)


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E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hyper-vigilance, exaggerated startle response, motor restlessness)

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about traumatic experience.


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G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

H. The disturbance is not due to the direct physiological effect of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.


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Diagnostic Criteria for Post Traumatic Stress Disorder (DSM-IV-TR)A. The person has been exposed to a

traumatic event in which both of the following were present:1. 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.

2. The person’s response involved intense fear, helplessness, or horror. In children, this may be expressed instead by disorganized or agitated behavior.


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Diagnostic Criteria for PTSD (DSM-IV-TR)B.The traumatic event is persistently re-

experienced in one (or more) of the following ways:1. 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.

2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated.) Note: in young children, trauma-specific reenactment may occur.

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.


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Diagnostic Criteria for PTSD(DSM-IV-TR), cont.C. Persistent avoidance of stimuli associated with the

trauma and numbing of the general responsiveness (not present before the trauma), as indicated by three (or more) of the following:1. Efforts to avoid thoughts, feelings, or conversations

associated with the trauma2. Efforts to avoid activities, places, or people that arouse

recollections of the trauma3. Inability to recall an important aspect of the trauma4. Markedly diminished interest or participation in

significant activities5. Feelings of detachment or estrangement from others6. Restricted rang 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 lifespan)


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Diagnostic Criteria for PTSD(DSM-IV-TR), cont.

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:1. Difficulty falling or staying asleep2. Irritability or outburst of anger3. Difficulty concentrating4. Hyper-vigilance5. Exaggerated startle response


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Diagnostic Criteria for PTSD (DSM-IV-TR), cont.

E. Duration of the disturbance (symptoms in Criteria B, C and D) is more than 1 month

F. The disturbance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning


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Specify if:

• 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


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Diagnosis of Post Traumatic Stress Disorder in children and adolescents

• Researchers and clinicians are beginning to recognize that PTSD may not present itself in children the same way it does in adults Criteria for PTSD now include age-specific features for some symptoms.


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Very young children may present with few PTSD symptoms • This may be because eight of the PTSD

symptoms require a verbal description of one's feelings and experiences.

• These children may also display posttraumatic play in which they repeat themes of the trauma.

• Children may lose an acquired developmental skill (such as toilet training) as a result of experiencing a traumatic event.


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Elementary school-aged children may not experience visual flashbacks or amnesia for aspects of the trauma. • They experience "time skew" and "omen

formation," which are not typically seen in adults.

• School-aged children also reportedly exhibit posttraumatic play or reenactment of the trauma in play, drawings, or verbalizations.

• Posttraumatic play is different from reenactment in that posttraumatic play is a literal representation of the trauma, involves compulsively repeating some aspect of the trauma, and does not tend to relieve anxiety.


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Adolescents may begin to more closely resemble PTSD in adults. • Adolescents are more likely to engage in

traumatic reenactment, in which they incorporate aspects of the trauma into their daily lives.

• Adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviors.


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Vicarious Trauma

• This term refers to the stress and trauma reactions that can occur in response to witnessing or hearing about traumatic events that have happened to others. In these cases, other people are the victims, and you see them undergoing suffering, or hear about traumatic events that have happened to them.


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Co-Occurring Disorders and Post Traumatic Stress Disorder • When these symptoms are present for a

prolonged period of time, they often begin to develop into “Co-Occurring Disorders” that may begin to take on a life of their own and begin to appear independent of any identifiable PTSD symptomology.


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Re-experiencing Symptoms

• Trauma survivors commonly continue re-experiencing their traumas. Re-experiencing means that the survivor continues to have the same mental, emotional, and physical experiences that occurred during or just after the trauma.


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Mentally re-experiencing the trauma can include:

• Upsetting memories such as images or other thoughts about the trauma.

• Feeling as if it the trauma is happening again ("Flashbacks").

• Bad dreams and nightmares. • Getting upset when reminded about the trauma

(by something the person sees, hears, feels, smells, or tastes).

• Anxiety or fear - feeling in danger again. • Anger or aggressive feelings or feeling the need

to defend oneself. • Trouble controlling emotions because reminders

lead to sudden anxiety, anger or upset. • Trouble concentrating or thinking clearly.


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People also can have physical reactions to trauma reminders such as:

• Trouble falling or staying asleep. • Feeling agitated and constantly on the

lookout for danger. • Getting very startled by loud noises or

something or someone coming up on you from behind when you don't expect it.

• Feeling shaky and sweaty. • Having your heart pound or having trouble

breathing.


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Avoidance Symptoms: • Because thinking about the trauma and

feeling as if you are in danger is so upsetting, people who have been through traumas want to avoid reminders of trauma. Ways of avoiding thoughts, feelings, and sensations associated with the trauma can include:

• Actively avoiding trauma-related thoughts and memories.

• Avoiding conversations and staying away from places, activities, or people that might remind you of trauma.

• Trouble remembering important parts of what happened during the trauma.


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• "Shutting down" emotionally or feeling emotionally numb.

• Trouble having loving feelings or feeling any strong emotions.

• Finding that things around you seem strange or unreal.

• Feeling strange or "not yourself". • Feeling disconnected from the world

around you and things that happen to you.

• Avoiding situations that might make you have a strong emotional reaction.

• Feeling weird physical sensations. • Feeling physically numb. • Not feeling pain or other sensations. • Losing interest in things you used to enjoy

doing.

Avoidance symptoms, cont.


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“Secondary” and Associated PTSD Symptoms often diagnosed as Mental Health Disorders• Secondary symptoms are problems that come

about because of having post-traumatic re-experiencing and avoidance symptoms.

• Over time, secondary symptoms can become more troubling and disabling than the original re-experiencing and avoidance symptoms.

• Associated symptoms are problems that don't come directly from being overwhelmed with fear, but happen because of other things that were going on at the time of the trauma. For example: a person who gets psychologically traumatized in a car accident might also get physically injured and then get depressed because he can't work or leave the house.


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These problems can be secondary or associated trauma symptoms: • Depression: can happen when a person has

losses connected with the trauma situation or when a person avoids other people and becomes isolated.

• Despair and hopelessness: can happen when a person is afraid that he or she will never feel better again.

• Loss of important beliefs: can happen when a traumatic event makes a person lose faith that the world is a good and safe place.

• Aggressive behavior toward oneself or others: can happen due to frustration over the inability to control PTSD symptoms (feeling that PTSD symptoms "run your life.


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These problems can be secondary or associated trauma symptoms, cont.• Self-blame, guilt, and shame: can happen

when PTSD symptoms make it hard to fulfill current responsibilities.

• Social isolation: can happen because of social withdrawal and a lack of trust in others. This often leads to loss of support, friendship, and intimacy, and grows fears and worries.

• Problems with identity: can happen when PTSD symptoms change important things in a person's life, like relationships or whether a person can do your work well.

• Feeling permanently damaged: can happen when trauma symptoms don't go away and a person doesn't think they will get better.


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These problems can be secondary or associated trauma symptoms, cont.• Problems with self-esteem: can happen

because PTSD symptoms make it hard for a person to feel good about him or herself. Sometimes, because of things they did or didn't do at the time of trauma, survivors feel that they are bad, worthless, stupid, incompetent, evil, and so on.

• Physical health symptoms and problems: can happen because of long periods of physical agitation or arousal from anxiety.

• Alcohol and/or drug abuse: can happen when a person wants to avoid bad feelings that come with PTSD symptoms, or when other things that happened at the time of trauma lead a person to take drugs.


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These problems can be secondary or associated trauma symptoms, cont.• Problems in relationships with people:

can happen because people who have been through traumas often have a hard time feeling close to people or trusting people. This may be especially likely to happen when the trauma was caused or worsened by other people (as opposed to an accident or natural disaster).

• Feeling detached or disconnected from others: can happen when a person has difficulty in feeling or expressing positive feelings. After traumas, people can get wrapped up in their problems or get numb and then stop putting energy into their relationships with friends and family.


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These problems can be secondary or associated trauma symptoms, cont.• Getting into arguments and fights with

people: can happen because of the angry or aggressive feelings that are common after a trauma. Also, a person's constant avoidance of social situations (such as family gatherings) may annoy family members.

• Less interest or participation in things the person used to like to do: can happen because of depression following a trauma. Spending less time doing fun things and being with people means a person has less of a chance to feel good and have pleasant interactions.


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Complex PTSD• Complex PTSD (sometimes called "Disorder of

Extreme Stress") is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse.

• Developmental research is revealing that many brain and hormonal changes may occur as a result of early, prolonged trauma, and contribute to difficulties with memory, learning, and regulating impulses and emotions.

• As adults, these individuals often are diagnosed with depressive disorders, personality disorders or dissociative disorders.

• Treatment often takes much longer, may progress at a much slower rate, and requires a sensitive and structured treatment program delivered by a trauma specialist.


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Ensuring Proper Treatment of Trauma and PTSD• Treatment for PTSD typically begins with a

detailed evaluation, and development of a treatment plan that meets the unique needs of the survivor.

Generally, PTSD-specific-treatment is begun only when the survivor is safely removed from a crisis situation. Educating trauma survivors and their families about how persons get PTSD, how PTSD affects survivors and their loved ones, and other problems that commonly come along with PTSD symptoms. Understanding that PTSD is a medically recognized anxiety disorder that occurs in normal individuals under extremely stressful conditions is essential for effective treatment.


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Ensuring proper treatment of trauma and PTSD, cont.• Exposure to the event via imagery allows the

survivor to re-experience the event in a safe, controlled environment, while also carefully examining their reactions and beliefs in relation to that event.

• Examining and resolving strong feelings such as anger, shame, or guilt, which are common among survivors of trauma.

• Teaching the survivor to cope with post-traumatic memories, reminders, reactions, and feelings without becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy, but become manageable with new coping skills.


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Best Practice Approach to Treat PTSD: • Cognitive-behavioral therapy (CBT)

involves working with cognitions to change emotions, thoughts, and behaviors.

• Exposure therapy is one form of CBT unique to trauma treatment which uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context, to help the survivor face and gain control of the fear and distress that was overwhelming in the trauma.

• In some cases, trauma memories or reminders can be confronted all at once ("flooding").


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• For other individuals or traumas it is preferable to work gradually up to the most severe trauma by using relaxation techniques and either starting with less upsetting life stresses or by taking the trauma one piece at a time ("desensitization").

• CBT for trauma includes learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts ("cognitive restructuring"), managing anger, preparing for stress reactions ("stress inoculation"), handling future trauma symptoms, as well as addressing urges to use alcohol or drugs when they occur ("relapse prevention"), and communicating and relating effectively with people ("social skills" or marital therapy).

Best practice approach to treat PTSD, cont.


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Group Treatment


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Components of PTSD Treatment:• Learning about trauma and PTSD.

• Talking to another person for support.

• Talking to your doctor about trauma and PTSD.

• Practicing relaxation methods.

• Increasing positive distracting activities.

• Taking prescribed medications to tackle PTSD.


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Components of PTSD Treatment:• Negative Coping Actions

• Use of alcohol or drugs.

• Social isolation.

• Anger.

• Continuous Avoidance.


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How is PTSD treated in children and adolescents?• Some children show a natural remission in PTSD

symptoms over a period of a few months, a significant number of children continue to exhibit symptoms for years if untreated.

• Few treatment studies have examined which treatments are most effective for children and adolescents.

• CBT for children generally includes the child directly discussing the traumatic event (exposure), anxiety management techniques such as relaxation and assertiveness training, and correction of inaccurate or distorted trauma related thoughts.

• CBT also involves challenging children's false beliefs such as, "the world is totally unsafe." The majority of studies have found that it is safe and effective to use CBT for children with PTSD.


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CBT is often accompanied by psycho-education and parental involvement• Play therapy can be used to treat young children with

PTSD who are not able to deal with the trauma more directly.

• Psychological first aid.• Twelve Step approaches have been prescribed for

adolescents with substance abuse problems and PTSD.• Eye Movement Desensitization and Reprocessing

(EMDR) combines cognitive therapy with directed eye movements. While EMDR has been shown to be effective in treating both children and adults with PTSD, studies indicate that it is the cognitive intervention rather than the eye movements that accounts for the change.

• Specialized interventions may be necessary for children exhibiting particularly problematic behaviors or PTSD symptoms. For example, a specialized intervention might be required for inappropriate sexual behavior or extreme behavioral problems.


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Psycho-pharmacology (Basic overview for non-medical professionals)

• Medications can reduce the anxiety, depression, and insomnia often experienced with PTSD, and in some cases may help relieve the distress and emotional numbness caused by trauma memories.

• As of December 2001, two medications are approved for treating PTSD by the U.S. Food and Drug Administration (FDA), sertraline (Zoloft) and paroxetine (Paxil), both selective serotonin reuptake inhibitors (SSRIs). FDA approval is based on multi-center double-blind studies.

• In addition to proven effectiveness, SSRIs are considered the first-line medication treatment for PTSD because their side effects are fewer and less troubling.


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Psycho-pharmacology, cont.

• The Expert Consensus Guidelines also saw promise in two comparatively new antidepressants: nefazodone (Serzone) and venlafaxine (Effexor) as second-line treatment if SSRIs prove ineffective or are not well tolerated. They have a more favorable side-effect profile than the tricyclics.

• Tricyclic antidepressants (TCAs) could be employed if the person has had a good response to them in the past and they do not cause too many side effects, or if the person has failed to respond to or does not tolerate the SSRIs, nefazodone or venlafaxine. Mood stabilizers may be added to improve a partial response to an antidepressant.


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Psycho-pharmacology, cont.

• Anti-anxiety medications (anxiolytics), including benzodiazepines, are ideally used only briefly and intermittently, if at all, to quell acute and severe anxiety symptoms. While they reduce anxiety rapidly, they also often induce sedation, impaired coordination and the development of physical dependency in those who use them for more than a few weeks.

• Gabapentin (Neurontin) is sometimes used in the place of benzodiazepines because it has similar benefits and does not cause dependency.

• Buspirone (BuSpar) may be a helpful adjunctive treatment for anxiety symptoms in people with PTSD, although evidence for its effectiveness is limited.


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Psycho-pharmacology, cont. • Monoamine oxidase inhibitors (MAOIs) have also

been shown to be helpful in PTSD. However, MAOIs are rarely used because of more frequent side effects than found with SSRIs and because a careful diet must be followed to prevent dangerous increases in blood pressure.

• If a medication is well tolerated, most people will continue to take it for 6 to 12 months if they have acute PTSD (less than 3 months duration) and for at least 12 and as long as 24 months for chronic PTSD before trying to taper off the medication.

• If PTSD symptoms return when medication is being discontinued, the effective dose would be resumed and usually continued for an even longer time before discontinuation is tried again.

Documents

PCCYFS 2012 Annual Spring Conference Advanced Trauma Interventions for Adolescent with Co-Occurring Mental Health Disorders Presented By: John P. Seasock