Trauma: Symptoms, Diagnosis and Treatment

1. 2006 Forensic Mental Health Association Conference A Time of Hope, A Time for Vision February 16, 2006 Seaside, California Trauma: Symptoms, Diagnosis and Treatment Mark Kamena, Ph.D. markkamena@comcast.net 415-717-3447

2. How The Brain Processes Threats (and what you can do about it) • Anatomy and Physiology of Threats • Autonomic Nervous System • Psychological Responses • Diagnoses • Assessment • Treatment • Residential Treatment Program for Emergency Responders

3. Brain Stuff • Every time you learn something or acquire a new experience your brain's cells suffer a modification • The brain exists in a delicate balance (homeostasis) where subtle changes may throw it into dysfunction ( Fever, Trauma and Delirium) • Conditioned emotional response

4. One Way of Understanding the Brain Reptilian Brain Physical Response External World / Internal Response. Limbic Brain Conscious Thought / Action / Planning. Cortical Brain

5. Event Reaction: HorrorFearSadnessVulnerabilityAnger Stimulus Our fear reaction is a biological adaptation that evolved to help us survive

6. ANGER Confusing Emotions Event Response “You triggered my automatic response system” “You’re an asshole” Classical Conditioning

7. What happens to your body under stressful conditions? – Another Perspective

8. Autonomic - primarily involuntary movements • Sympathetic – (Stress) • Parasympathetic (At Rest)

9. Heart, Lungs, and Circulation • Heart rate and blood pressure increase instantaneously • Blood flow may actually increase 300% to 400%

10. Heart, Lungs, and Circulation • Spleen increases red blood cells into bloodstream to promote oxygen supply. • As blood moves into muscles, blood vessels tighten causing vasoconstriction.

11. Immune System's Response • Infection fighting systems (white blood cells, etc) are redistributed • Immunity boosting agents are sent to the skin, bone marrow and lymph nodes

12. Mouth and Throat Response • Fluids are diverted from nonessential locations, including the mouth • Can make it difficult to talk.

13. Skin's Response • Diverts blood flow away from the skin to support the heart and muscle tissues • This causes cool, clammy, sweaty skin

14. Skin's Response • Scalp also tightens so that the hair seems to stand up

15. Metabolic Response • Stress shuts down digestive activity – a non essential activity

16. Physical Responses After The Event • Fatigue • Aches and pains • Eating changes • Gastrointestinal problems

17. Psychological and Emotional Responses

18. Normal Psychological Responses During the Event • Dissociation • Denial Response

19. Normal Emotional Response: • Frustration • Anger • Fear • Sadness • Numbness • Guilt

20. Normal Emotional Response • Helplessness • Lack of Control • Irritability • Excitement • Vulnerability

21. Normal Psychological ResponsesAfter the Event Sleep Disturbance and Nightmares

22. Normal Psychological ResponseAfter the Event • Sudden mood changes • Anxiety • Depression • Anger • Headaches

23. Normal but ProblematicPsychological Responses • Withdrawal • Sleep problems • Anxiety / fear

24. Normal but ProblematicPsychological Responses • Hyper-vigilance • Aggressiveness • Feeling out of control • Survivor’s guilt

25. Problematic Responses to Traumatic Stress • Family Fights • Eating too much or too little • Passivity or Aggression on the job

26. Problematic Responses to Traumatic Stress • Black / White thinking • Alcohol and Drug Abuse

27. Normal Cognitive Response: • Preoccupation with the event • Second Guessing • Poor Concentration • Difficulty with problem solving • Memory problems

28. Most Common Reactions • Second Guessing • Heightened Sense of Danger • Legal Concerns • Vulnerability • Flashbacks • Fearing Future Situations

29. Common Diagnoses • PTSD • Acute Stress Disorder • Mood Disorder • Anxiety Disorder • Emergency Responder Exhaustion Syndrome • DESNOS – Complex PTSD • Substance-Related • (in partial or full remission) • Adjustment Disorder • Eating Disorder • Sleep Disorder

30. PTSD As We Knew It DSM I – Gross Stress Reaction DSM II – Adjustment Disorder DSM III - PTSD • Outside the realm of normal human experience • Single stress incident • Paradigm shift away from exacerbation of existing pathology

31. PTSD • PTSD is a total person experience • Symptoms effect • Mental Health • Physical Health • Family and Friends • Work • Spirit

32. PTSD • Must be exposed to a traumatic event • The event must be re-experienced by distressing recollections, dreams, flashbacks, etc. • Avoidance of locations, persons, etc • Persistent problems falling or staying asleep, irritability, Hyper-vigilant, etc.

33. PTSD – Diagnostic Criteria Must be exposed to a traumatic event Person's response to the event must involve intense fear, helplessness, or horror

34. The event must be re-experienced by distressing recollections, dreams, flashbacks, etc.

35. Avoidance of locations, persons, etc • Sense of isolation • “No one else knows what I am going through” • “I can’t burden other people with this.”

36. Persistent Problems With Increased Arousal • Withdrawal • Irritability • Insomnia • Hyper-vigilant

37. The symptoms are the body’s way of healing itself

38. DESNOS - Complex PTSD • Childhood Trauma • Cumulative • Interpersonal

39. Some Common Factors • Severity of the incident • Nature of the trauma – interpersonal vs. natural disaster • History of childhood sexual abuse or adversity • Use of avoidance coping strategies. • Vulnerability / Resiliency impaired

40. How to assess and/or diagnose PTSD?

41. The DAPS components are: • Response Validity [16 items) • Trauma specification [14 items] • Immediate trauma impacts [14 items] • Peritraumatic Distress [8 items] • Peritraumatic Dissociation [6 items] • Posttraumatic response [35 items]

42. The DAPS components are: • Posttraumatic response [35 items] • Reexperiencing [10 items] • Avoidance [10 items] • Hyperarousal [10 items] • Posttraumatic Impairment [5 items]

43. The DAPS components are: • Supplementary scales [24 items] • Trauma-specific Dissociation [4 items] • Substance Abuse [10 items] • Suicidality [10 items]

44. Cool Information … But What Does it Mean? • A lot of how we react is beyond our control but does not mean we are weak or worthless. • Now that you know what causes the symptoms what can you do about it?

45. Treatment Models

46. Short Term vs. Long Term • Cognitive Behavioral vs. Relational / Psychodynamic • Utilizing the Best of Each

47. Medications • Anti-Depressants • Sleep • Arousal / Anxiety • Dissociation

48. EMDR

49. Relapse Prevention • In Therapy • Anticipation and Rehearsal • Role Play • Systematic Desensitization • Relaxation

50. A Residential Program Example: West Coast Posttrauma Retreat (WCPR) • Involvement of the peers, clinicians and chaplains at WCPR is all pro-bono. • The primary motivating factor for staff is a deep pride coupled with concern for the emergency service responder.