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POST TRAUMATIC STRESS DISORDER

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					POST TRAUMATIC STRESS
      DISORDER

      Nov 24, 2008
            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
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
     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”
         Avoidant Behaviors
 Avoidance of triggering activities, places
 Restricted affect - avoidance of thoughts &
  feelings…feelings often experienced as
  somatic symptoms
 Psychogenic amnesia – inability to
  remember certain aspects of trauma
 Avoidance of relationships – distancing
 Decreased play/participation
           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
                    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
              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
         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)
    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)
  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
 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
                   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)
     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
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)
          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
     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
                  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
     Psychotropic Medications
 Anti-depressants, anti-anxiety such as
  SSRI’s and Wellbutrin
 Mood stabilizers (e.g., Lithium)
 Anti-aggressives (e.g., Risperdal)
 Stimulants/attentional agents such as
  Concerta, Ritalin, Dexadrine, Clonidine
 Sleep agents (Imiprimine)
          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 don’t need to know every detail of harm done to help

 Need to teach skills for symptoms (relaxation, coping)
      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)
        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

				
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