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 & feelings…feelings 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 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)

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 don’t 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