POST TRAUMATIC STRESS DISORDER

1
POST TRAUMATIC STRESS DISORDER

• Nov 24, 2008

2
Trauma vs Stress

• Trauma refers to experiencing or witnessing
  events that lead to actual or threatened death or
  injury of self or others
• Events exceed and overwhelm the coping of most
  people intense fear, helplessness, horror
• Examples include war, kidnapping, violent
  personal assault, disasters, severe MVA
• In North American children, develops most often
  in children experiencing sexual abuse or
  witnessing domestic violence

3
Core Features DSM IV - TR

• 1) persistent re-experiencing of the event,
• 2) avoidance of associated stimuli numbing of
• general responsiveness
• 3) symptoms of extreme arousal
• 4) duration of symptoms last at least 1 month and
• result in significant functional impairment

4
Re-experiencing Trauma

• Recurrent intrusive memories
• Recurrent nightmares in which event is replayed
  or represented
• Dissociative flashbacks where person may behave
  as though currently experiencing the event. This
  is not just a memory

5
Avoidant Behaviors

• Avoidance of triggering activities, places
• Restricted affect - avoidance of thoughts
  feelingsfeelings often experienced as somatic
  symptoms
• Psychogenic amnesia inability to remember
  certain aspects of trauma
• Avoidance of relationships distancing
• Decreased play/participation

6
Arousal Symptoms

• Trouble falling or staying asleep
• Physical stress (Eating or elimination problems,
  pain, headaches, stomachaches, vomiting)
• Exaggerated startle response
• Hypervigilance (wariness, dress)
• Increased aggression (others, animals, objects)
• Increased irritability, crying
• Difficulty concentrating, completing tasks

7
History

• US Civil War soldiers heart
• WW I combat fatigue
• WWII gross stress reaction or shell shock
• formal diagnosis in 1980
• Many developed PTSD despite not directly
  witnessing the events of 9-11 terrorist attacks

8
Prevalence

• 40 of kids have endured at least 1 traumatic
  event
• 4 6 of boys PTSD
• 6 to 15 of girls PTSD
• About 8 of people will develop PTSD in their
  lifetime (more women than men)
• 10 to 30 of combat vets rape victims will
  develop the disorder

9
Childhood Presentation

• Developmental regression (bedwetting, babytalk)
• Nightmares
• Heightened fearfulness
• Poor affect regulation
• Panic attacks
• Aggressive/destructive behaviors (rage)
• Trauma re-lived through play or art
• Memory problems
• Suppressed immune functioning (digestive, skin
  respiratory problems)

10
Distortion of Core Self Processes Related to
Early Trauma

• Motivational passivity
• Attitudinal negativity
• Emotional expression regulation
• Relational intrusive, aggressive, hostile
• G. Crisci N. Mayer (2007)

11
Effects of Trauma on Infant Brain Development

• Crucial period for maturation of limbic
  cortical regions is during the first 2 years of
  life
• The internalization of the early caregiving
  relationship occurs in the frontal limbic system
  of the brain

12
PTSD Neurological Changes

• HPA axis higher levels of stress hormones
• Smaller hippocampus volumes related to stress
  hormones
• Amygdala disinhibited, promotes fear reaction
  when no danger present

13
Quote

• Sensitive and secure caregiving is essential in
  the very early infant years in order for the
  primitive brain to evolve. When good caregiving
  is not provided, the more advanced functions of
  the brain that regulate intellectual, emotional
  and social maturation do not develop normally
• G. Crisci (2007)

14
Disorganized Attachment

• Caregivers are severely neglectful and physically
  or sexually abusive
• Behaviors can look like ADD disorganized,
  impulsive, clumsy, low frustration tolerance,
  seek instant gratification
• Behavioral interventions often escalate the
  behavior b/c child is craving an attachment
  response

15
Amnesia explained by neurobiology?

• Chronic release of stress hormones from limbic
  system interferes with ability to capture
  experience in words or symbols stress also
  interferes with storage categorization of
  memory (hippocampus)
• Failure of semantic memory leads to organization
  of memory on a somatosensory level decreased
  inhibitory control may occur during sleep, with
  strong reminders of the event, drugs alcohol
• Van der Kolk, B.A. (1995)

16
PTSD Risk Factors

• Longer duration of traumatic event
• More severe traumatic event
• Poorer pre-traumatic emotional adjustment
• Few social supports
• Younger age children more at risk
• Females
• Learning disability
• Violence in the home

17
PTSD Protective Factors

• Those with disaster training less likely to
  develop PTSD (e.g., paramedics, police,
  firefighters, MH medical professionals)
• Concept of vicarious trauma
• Circle of support

18
Treatment

• Behavior therapy- exposure to feared stimulus,
  while providing ways of coping other than escape
  and avoidance
• Cognitive-behavioral therapy- teaches
  modification of maladaptive thoughts to decrease
  symptoms (most effective for most anxiety
  disorders)
• Eye movement desensitization reprocessing
  (EMDR)
• Family interventions may result in more dramatic
  and long-lasting effects

19
Psychotropic Medications

• Anti-depressants, anti-anxiety such as SSRIs and
  Wellbutrin
• Mood stabilizers (e.g., Lithium)
• Anti-aggressives (e.g., Risperdal)
• Stimulants/attentional agents such as Concerta,
  Ritalin, Dexadrine, Clonidine
• Sleep agents (Imiprimine)

20
Treatment Implications

• Course of PTSD marked by remissions relapses
• Anxious feelings may occur at an unconscious
  level or at the level of procedural memory
• Preverbal memories may surface as bodily
  reactions
• Talk therapy may be limited when limbic responses
  are hard-wired (e.g., insight-oriented
  cognitive therapies)
• We dont need to know every detail of harm done
  to help
• Need to teach skills for symptoms (relaxation,
  coping)

21
Treatment Implications

• Need to maximize protective factors
• Need to externalize the trauma (art, drama,
  scrapbooks)
• Neutralizing sensorial reminders (5 senses)
• Need to address cognitive distorations (e.g.,
  assignment of responsibility)

22
Research Challenges

• Most research with adults
• Most research with Type II trauma or abuse
• Studies separate physical, sexual witnessing
  violence people with complicated histories are
  screened out
• Typically multiple family stressors
• Parents with mental health problems