Background of PTSD Psychic 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 Criteria Exposure 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 Children Bus 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 Children Must 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 Trauma Type I Trauma Sudden and distinct traumatic experience Type II Trauma (aka “complex PTSD”) Persistent and derives from repeated traumatic events Has 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 Type Incidence 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 Archetype Hyper-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 PTSD Intrusive-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 PTSD Death 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 Afghanistan Comprehensive 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 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