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Post Traumatic Stress Disorder by sammyc2007


									Post Traumatic Stress
    Kevin Tobin, Ph.D.
DSM-IV Diagnostic Criteria for PTSD
   Exposure to a traumatic event in which the
     – experienced, witnessed, or was confronted by
       death or serious injury to self or others AND
     – responded with intense fear, helplessness, or
   Symptoms
     – appear in 3 symptom clusters: re-
       experiencing, avoidance/numbing, hyper
     – last for > 1 month
     – cause clinically significant distress or
       impairment in functioning
  Diagnostic Criteria for PTSD

 Persistent re-experiencing of  1 of the
   – recurrent distressing recollections of
   – recurrent distressing dreams of event
   – acting or feeling event was recurring
   – psychological distress at cues
     resembling event
   – physiological reactivity to cues
     resembling event
  Diagnostic Criteria for PTSD
 Avoidance of stimuli and numbing of general
  responsiveness indicated by  3 of the following:
   – avoid thoughts, feelings, or
   – avoid activities, places, or people*
   – inability to recall part of trauma
   –  interest in activities
   – estrangement from others
   – restricted range of affect
   – sense of foreshortened future
  Diagnostic Criteria for PTSD

 Persistent symptoms of increased
 arousal  2:
  – difficulty sleeping
  – irritability or outbursts of anger
  – difficulty concentrating
  – hypervigilance
  – exaggerated startle response
  History of the Trauma
 Freud believed that an event could
  be so unmanageable that the
  individual would feel overwhelming
 DSM-I called this condition a gross
  stress reaction. Then DSM-II forgot
  it and called it an adjustment
 Finally, after Vietnam, the DSM-III
  PTSD was defined.
  Symptoms and Children
 The requirement that a child have
  three symptoms of denial or
  avoidance may be too restrictive.
 French researchers found many
  children exposed to a traumatic
  event had subclinical PTSD ( They
  lacked one symptom of avoidance
  and one of arousal.)
      Effect of Trauma
 Most symptoms of PTSD apply to
 children of all ages as well as adults.
 On the average 36% of children
 exposed to a traumatizing event
 incur PTSD, whereas 24% of adults
 who are exposed to trauma develop
     Prevalence of Trauma and Probability of
    40                         Prevalence of Trauma                       Male
    30                                                                    Fem ale

%   20


         Witness   Accident   Threat w/ Physical                            Rape
                              Weapon Attack        Molestation   Combat

  70                             Probability of PTSD
% 40
         Witness   Accident   Threat w/   Physical Molestation Combat        Rape
                              Weapon       Attack
    Prevalence of PTSD
 Estimated Lifetime prevalence 7.5 %
 Frederick 1985 study indicates that
  5.4% of children met the A to D
  criteria of PTSD
 6.9% of girls
 3.8% of boys met the criteria.
 Cuffe (1998) 3.5% of 1618 randomly
  selected students had PTSD
Impaired Quality of Life with PTSD
 100   MDD
       US Population



              Vitality   Social Function
     Comorbidity in PTSD with
60                                                   Males





     Major    GAD    Panic     Social    Agora    Alcohol  Drug
     Depressive     Disorder   Anxiety   phobia   Abuse/   Abuse
    Types of Stressors

 Type I Trauma : Acute non-abusive
 stressors, which include traumatic
 events that occur only once.

 Type II Trauma: Chronic or abusive
 stressors which include recurring
 multiple stressors
     Effects of Stressors
 In the case of cumulative trauma, the
  child experiences an aggregate of shocks
  to his system with each incident leaving
  the child more vulnerable.
 Type II trauma is associated with
  additional psychopathology.
 These include a maladaptive attribution
  style, dissociation ( numbing denial)
  deficient coping strategies and poor
  response to anger.
Associated Disorders
  ADHD may put child at risk by
   making them more likely to
   experience physical abuse.

  Some studies show no association
   between ADHD and PTSD.
     Construing Trauma
 Beliefs PTSD response may represent a
  survivors way to accommodate these
  extreme experiences into one’s cognitive
 In some cases traumatic memories
  dissociate from normal consciousness, but
  continue to have an unconscious effect.
 In some models of PTSD, cognitive
  appraisals mediate a child’s emotional
  reactions to traumatic events
     Construing Trauma
 Some events become traumatic when they
  shatter one’s belief about the world.
 Studies of sexually abused children
  indicate they believe the word is
  dangerous, it is uncontrollable by them,
  and adults are untrustworthy.
 There is little evidence for a biological
  predisposition to PTSD.(Few studies have
  been done and none with children.)
   Assessment of PTSD
 Standard psychoeducational
  assessment techniques must be
 Administer comprehensive
  structured interviews and use
  trauma specific measures in addition
  to more general psychological
   Assessment of PTSD
 Final reports should contain:
 Academic functioning including a review
  of records, cognitive and academic skills
 Behavioral Assessment - including
  behavior observations.
 PTSD measures (parent child and teacher
 Symptom severity measures.
 Developmental sensible
      Assessment Risks
 Doing a assessment of a child with
  possible PTSD can be threatening and
  symptom inducing.
 Children who experienced trauma often
  have trouble verbalizing their
  experiences, which can lead to
 The symptoms of PTSD are similar to
  other disorders including: mood
  disorders, conversion disorder,
  obsessive-compulsive disorder, brief
  psychotic disorder, and substance abuse
 Pre School Symptoms of
 Pre school symptoms tend to be
  nonverbal and include:
 Internalized behavior, aggressive
  behavior, nightmares, disturbed
  sleep, developmental regression,
  and clinging.
 Traumatic play is often related to
  the traumatic events and appears to
  be compulsive and repetitive and
  does not relieve anxiety
  School Age Symptoms
 Symptoms continue to be behavioral
  and can include regression,
  externalized or internalized
 They may report symptoms by
  listing concrete physiological
 Sleep disturbance is common.
 Re-experiencing is can be presented
  through elaborate enactment of the
   Adolescent Symptoms
 Adolescents symptoms become more and
  more similar to adult symptoms.
 Adolescents may believe that their future
  will be effected and foreshortened.
 Those who experienced Type II trauma
  are more likely to be suicidal, dissociate,
  experience derealization,
  depersonalization and engage in
  substance abuse.
 Academic Consequences
 Lower scores on standardized tests
 Lower school achievement
 More frequent grade retention
 Lower grades
 PTSD can compromise the capacity
  for reflection and focused attention.
 Type II Trauma is particularly
Cognitive Affects of Trauma
 Neumberger (1997) and Teicher (2003)
  indicate that children who experience
  extensive repeated trauma experience
  shrinkage in the areas of the brain
  associated with memory, learning,
  emotional regulation and language.
  Language functioning can be particularly
 Trauma can effect narrative coherence
  which effects oral communication, reading
  and writing.
 Cognitive Behavioral therapy has the
 most empirical support as a
 treatment for children with PTSD It
 works by uncoupling the pairing
 between traumatic stimuli / cognitive
 events and an anxiety response. It
 replaces this pairing with a learned
 relaxation response and logical
Things to look for in school:
 Emotional             Behavioral
  symptoms: such as      Symptoms: such as
  flat affect, panic     reenactment or
  attacks.               showing traumatic
 Cognitive              images in play or
  Symptoms: such as      drawings.
  frequent intrusive
  memories, suicidal
  ideation memory
    School Reintegration
 Relapse risk can be decreased with
  reintegration planning.
 Have a meeting to plan reentry before the
  student returns. The school psychologist
  should consult with the child’s treatment
  team before reentry.
 Educate the family, school personnel and
  the child about PTSD and recovery.
 This education includes the recovery
  process, coping skills, relaxation, and
  relapse prevention.
    School Reintegration
 Create an individualized plan that
  identify the needs goals and
  treatment parameters.
 This should include a schedule of
  meetings and a list of names and
  phone numbers of essential contacts.
 It should include preventative
  sessions that address anniversaries
  and high stress circumstances.
    School Reintegration
 Facilitated Integration is enhanced
  by considering the length of initial
  school visits, and how the length of
  time in school will be extended.
 It is important to consider the
  amount of time missed from school,
  inpatient status, level of peer
  support, level of family support,
  premorbid functioning, and mental
  health status.

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