Post Traumatic Stress Disorder Kevin Tobin, Ph.D. DSM-IV Diagnostic Criteria for PTSD Exposure to a traumatic event in which the person: – experienced, witnessed, or was confronted by death or serious injury to self or others AND – responded with intense fear, helplessness, or horror Symptoms – appear in 3 symptom clusters: re- experiencing, avoidance/numbing, hyper arousal – last for > 1 month – cause clinically significant distress or impairment in functioning Diagnostic Criteria for PTSD Re-experiencing Persistent re-experiencing of 1 of the following: – recurrent distressing recollections of event – 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/Numbing Avoidance of stimuli and numbing of general responsiveness indicated by 3 of the following: – avoid thoughts, feelings, or conversations* – 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 Hyperarousal Persistent symptoms of increased arousal 2: – difficulty sleeping – irritability or outbursts of anger – difficulty concentrating – hypervigilance – exaggerated startle response History of the Trauma Concept Freud believed that an event could be so unmanageable that the individual would feel overwhelming helplessness. DSM-I called this condition a gross stress reaction. Then DSM-II forgot it and called it an adjustment reaction. 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 PTSD Prevalence of Trauma and Probability of PTSD 40 Prevalence of Trauma Male 30 Fem ale % 20 10 0 Witness Accident Threat w/ Physical Rape Weapon Attack Molestation Combat 70 Probability of PTSD 60 50 % 40 30 20 10 0 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 PTSD 100 MDD OCD US Population 75 50 25 0 Vitality Social Function Comorbidity in PTSD with Adults 60 Males Females 50 40 30 20 10 0 Major GAD Panic Social Agora Alcohol Drug Depressive Disorder Anxiety phobia Abuse/ Abuse Dependence 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 system 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 supplemented. Administer comprehensive structured interviews and use trauma specific measures in addition to more general psychological measures. Assessment of PTSD Final reports should contain: Academic functioning including a review of records, cognitive and academic skills assessments. Behavioral Assessment - including behavior observations. PTSD measures (parent child and teacher reports) Symptom severity measures. Developmental sensible recommendations. 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 underreporting. 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 PTSD 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 behavior. They may report symptoms by listing concrete physiological complaints. 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 damaging. 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 affected. Trauma can effect narrative coherence which effects oral communication, reading and writing. Interventions 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 thinking. 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 disturbance 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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