Posttraumatic Stress Disorder Chapter Seven
Dec 08, 2014
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