1. FAMILIES IN CRISIS Chapter 7 - Posttraumatic Stress Disorder 1

2. MANY CRISES MAY BE ROOTED IN PTSD 1. Suicide 2. Substance abuse 3. Rape 4. Sexual abuse 5. Battering 6. Loss 7. Physical violence 8. Hostage situations 9. Natural and human-made disasters 2

3. DIAGNOSING PTSD (DSM-IV-TR, APA 2000) First (see page 152): * Person Exposed to a trauma/event that involved actual or threatened death or serious injury, or a threat to self or other's physical well-being. * Response is intense fear, helplessness, or horror. * As a result, has persistent symptoms of anxiety or arousal that were not evident before the trauma/event. 3

4. DIAGNOSING PTSD (DSM-IV-TR, APA 2000) Second (see page 152): * Person persistently re-experiences the traumatic event in at least one of the following: 1. Distressing recollections 2. Nightmares 3. Flashbacks 4. Intense distress from cues that symbolize event 5. Physiologic reactivity from cues 4

5. DIAGNOSING PTSD (DSM-IV-TR, APA 2000) Third (see page 152): * Person persistently avoids such stimuli in at least three of the following: 1. Thoughts, dialogues, or feelings about trauma 2. Activities, people, or situations about trauma 3. Inability to recall important aspects of trauma 4. Diminished interest in significant activities 5. Feels detached emotionally and socially 6. Numbing feelings 7. Sense of short future 5

6. DIAGNOSING PTSD (DSM-IV-TR, APA 2000) Fourth (See page 152) * Person has increased nervous system arousal as indicated by at least two of the following: 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating on tasks 4. On Watch for real or imagined threats 5. Startle reactions to minimal or non-threatening stimuli 6

7. DIAGNOSING PTSD (DSM-IV-TR, APA 2000) Fifth (see page 152): * Person has clinically significant distress or impairment in social, occupational, or other critical areas of living. * For more than one month. 7

8. INCIDENCE * About 8% for general civilians * About 20% after a trauma * Higher for at risk groups: 1. Adolescents and young adults 2. People in hazardous occupations 3. Sexual assault victims 4. Severe burn cases 5. Psychiatric cases 6. Refugees 7. War vets can be much higher. 8

9. WAR VETS - TERMS 1. Hypervigilance (alert all of the time) 2. Bonding (unit cohesion) 3. Debriefing time (adjusting to non-war life) 4. Guilt (survivors) 5. Dissociation (numbing or lack of emotional responsiveness) 6. Hyperarousal and/or acoustic startle response 9

10. 5 MALADAPTIVE PATTERNS OF PTSD 1. Death Imprint (continuing identity with death and sensation-seeking behaviors) 2. Survivors Guilt 3. Desensitizing oneself to totally unacceptable events, and then trying to return to a semblance of normalcy in a peaceful world (bipolar emotions) 4. Estrangement (from relationships and/or social services) 5. Emotional enmeshment (fixation on trauma keeps them from successful relationships/family functioning 10

11. TODAYS WAR VETS/SOLDIERS 1. 13-25% for Mid-East vets 2. Suicide rate increased 3. Women and men 4. Family impact 5. DOD is more proactive 6. Better Assessments 7. Better interventions 8. Better outreach programs 11

12. 3 COMPONENTS OF PTSD TREATMENT OF ADULTS 1. Processing and coming to terms with the experience 2. Controlling physiological and biological stress reactions 3. Reestablishing secure social connections and interpersonal efficacy 12

13. 3 GOALS IN ASSESSMENT FOR PTSD ADULTS 1. Are PTSD symptoms present? 2. Are drugs or personality disorders masking PTSD? 3. How is the event contextually interpreted by the person? 13

14. ASSESSMENTS FOR PTSD 1. Structured Interviews (Clinician-Administered PTSD Scale - CAPS-1, based on DSM-IV-TR) 2. Unstructured self-reports (time efficient - Traumagram Questionnaire 3. Emperically Derived Scales (typically population based) 14

15. PHASES OF RECOVERY FOR PTSD 1. The emergency or outcry phase (fight or flight) 2. The emotional numbing and denial phase (avoidance) 3. The intrusive-repetitive phase (nightmares, volatile mood swings, intrusive images, etc) - Now seeking help. 4. The reflective-transition phase (better perspective, coming to grips) 5. The integration phase (successfully integrates the trauma with other past experiences and restores a sense of continuity to life. Note: Cycles and trancrisis highly frequent 15

16. PSYCHOTROPIC MEDICATION 1. Some relief of psychophysiological responses 2. Prozac (antidepressant) 3. Clonidine (decrease arousal) 4. Requires careful prescription and monitoring with expertise 16

17. GROUP TREATMENT TYPES 1. Debriefing Groups (preventative, short term and typically for acute like-distress survivors of a common traumatic experience) 2. Support Group (longer term and typically composed of class-specific members who have been exposed to the same type of trauma but at different times and under different circumstances.) 17

18. PTSD GROUPS (2 PHASES) 1. Focus on accessing and working through the trauma and its symptoms. 2. Life Adjustment Group - Focus on the readjustment to contemporary society. (Behavioral change, coping, family etc.) 18

19. PTSD AND CHILDREN 1. US, 30 to 50% will experience at least one traumatic event by 18th birthday 2. US, 1 million cases (homegrown) child abuse per year 3. Of those with at least one trauma (3-16% girls, 1-6% boys) will develop PTSD 19

20. PTSD AND CHILDREN - TYPE OF TRAUMA 1. 100% of children will get PTSD if they see a parent killed or sexually assaulted 2. 90% of sexually abused children will develop PTSD 3. 77% of children who witness a school shooting 4. 35% of children who witness neighborhood violence 20

21. PTSD AND CHILDREN - TREATMENT 1. Depends on developmental stage 2. and Cognitive ability 3. Adult diagnosis is not the same (DSMs no longer captures what fits for children) 4. Support system is critical 5. Separation carries emotional and personality disturbance 6. Unresolved grieving is a major ingredient to pathology 21

22. TYPES OF CHILDHOOD TRAUMA 1. Current and aftereffects into adulthood have to be considered 2. Type I - sudden, distinct traumatic experience (detailed fully etched-in memories, misperceptions, mistiming of the event, etc.) 3. Type II - Long-standing and comes from repeated traumatic ordeals (psyche's developing defensive and coping strategies to ward off the assaults - such as denial, dissociation, repression psychic numbing, self aggression etc.) 22

23. TREATMENT OF CHILDHOOD PTSD 1. Early assessment is critical 2. Interviewing helps reduce long-term symptoms (but parents may be resistant) 3. Requires great skill with both Cogitive- Behavioral Therapy and Play Therapy 23

24. EMDR (ADULTS AND CHILDREN) 1. Eye Movement Desensitization and Reprocessing 2. Controversial 3. Requires specialized training 24