Chapter Seven: Posttraumatic Stress Disorder
Chapter Seven: Posttraumatic Stress Disorder
Background of PTSD
Psychic 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 Criteria
Exposure 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 Children
Bus 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 Children
Must 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 Trauma
Type I Trauma
Sudden and distinct traumatic experience
Type II Trauma (aka “complex PTSD”)
Persistent and derives from repeated traumatic events
Has 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 Type
Incidence
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 Archetype
Hyper-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 PTSD
Intrusive-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 PTSD
Death 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 Afghanistan
Comprehensive 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 Adults
Assessment
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