Post Traumatic Stress Disorder (PTSD) Flashcards
HMS
Chapter by Flecher (2006)
High Magnitude Stressor (HMS)
Multiple HMS common- 18% have two and 10% 3
Majority do not develop PTSD
Depends on complex interaction of the event itself (e.g. nature, cause, severity, duration, etc.). the child’s cognitive emotional, and psychobiological, and behavioral responses to the event; personal characteristics, previous exposure to and reaction other stressors, developmental stage, age, gender, and characteristics of the social environment.
PTSD vs. Acute Stress Disorder (ASD)
chronic vs. acute
Emotional Reaction
Requires emotional reaction of horror, fear, or helplessness to the high magnitude stressor.
Appraisals and Attributions
i. Appraisals
1. Evaluations concerning the importance of an event. Appraised an inescapable.
ii. Attributions
1. Self blame or guilt
2. Global attributions of causality.
Neurobiological Changes Due to Stressful Experiences
HMS lead to changes in brain structure and functioning, particularly in the hypothalamic-pituitary adrenal (HPA) axis (controls reactions to stress).
Biological factors
Not one gene involved (many genes)
Strengths and vulnerabilities
- Sense of self-efficacy (self-esteem)
- Previous exposure to high stressors
- Previous experience dealing with high stressors/Coping strategies
Social Factors
- Social support
- Parenting style
- Family dynamic
Shared Characteristics of the Three Posttraumatic Stress Syndromes
i. Reexperiencing, avoidance of reminders, and overarousal due to reminders of the stressful event(s).
ii. Difference is the time frame
PTSD Type 1 vs. Type 2
i. Division of traumatic events
1. Type 1 –acute high- magnitude (natural disasters, death, etc.) → usually results in ASD
2. Type 2 – prolonged duration (e.g. sexual and physical abuse) → usually results in complex PTSD
Prevalence
1 to 14% in children
Girls exhibit more internalizing vs. Boys more externalizing
Ethnic differences
- All experience it
- When exposed to type 1, non-European descent are more symptomatic
a. Hurrican Hugo → African American symptoms> Whites
b. African American & Hispanics not as good at coping - For type 2, Asians handle it best. However, they contemplate suicide more.
v. Cultural background affect how PTSD symptomology is manifested.
vi. Cultural bound syndromes
Criteria for DSM IV PTSD
A. Stressor B. Intrusive Recollection C. Avoidant/numbing D. Hyper-arousal E. Duration F. Functional Significance
Acute: if duration of symptoms is less than three months
Chronic: if duration of symptoms is three months or more
With or without delay onset: Onset of symptoms at least six months after the stressor
Acute Stress Disorder distinctions vs. PTSD
timing…before 6 months or after 6 months
dissociative symptomology…
i. extreme emotional disconnection; difficulty experiencing pleasure; temporary amnesia, or “dissociative amnesia” if the loss of memory centers more around the traumatic event itself; depersonalization (survivors feel detached from their traumatic experience); and derealization (survivors’ worlds seems strange and unfamiliar, and they may feel as though they are not “real”).
ASD good predictor of PTSD
Criteria for DSM IV Acute Stress Disorder
A. Event with both present:
- witnesses HMS
- response involved intense fear, helplessness, or horror
B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
(1) a subjective sense of numbing, detachment, or absence of emotional responsiveness
(2) a reduction in awareness of his or her surroundings (e.g., “being in a daze”)
(3) derealization
(4) depersonalization
(5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
H. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.
Complex PTSD
a. High comorbidity (80%)
b. Not recognized in the DSM IV
c. Symptom categories
i. Difficulties regulating affect and impulses
ii. Alterations in attention or consciousness
iii. Somatization
iv. Distorted self perception
v. Difficult relations with others
vi. Alterations in systems of meaning
d. Children do develop clusters of symptoms that bear a strong resemblance to the proposed syndrome of complex PTSD.
Assessment of PTSD Considerations
Age, developmental stage, reading level, verbal comprehension, type of stressor, purpose of assessment, duration, social environment, etc.
Assessment (from multiple sources)
- Obtain a history
a. Getting psychiatric history
b. Previous history of stressors can have an effect on how one reacts to new stressors.
c. Info on how one reacts to other stressors
d. Parents history of HMS as well as their reactions to child symptoms
i. Affect child’s coping - Developmental considerations
a. Pay attention to developmental variations in the child’s reactions because very younger children may show a different symptomology. - Understandability of questions
a. CPTS is example of bad questions for children - Assess the full range of responses
a. Should include assessment of ASD symptomology and complex PTSD.
b. When responses from different sources conflict, the child’s responses should be considered the most compelling, particularly if the questions concern internal processes.
Assessing Stressors
b. Assessing the stressor (is the child exaggerating?)
Assessing exposure to high-magnitude stressors
- Traumatic Events Screening Inventory (TESI)
ii. Assessing exposure to a range of stressors (not just HMS)
Assessing stressors in preschool and school-age children
i. Juvenile Victimization Questionnaire (JVQ)
1. Conventional crime
2. Child maltreatment
3. Peer and sibling victimization
4. Sexual victimization
5. Witnessing and indirect victimization
ii. Preschool Age Psychiatric Assessment (PAPA) Life Events Scale
1. High- and lesser-magnitude stressors in the lives of the very youngest children, ages 3-6 years
a. Reduction in family’s standard of living
b. Attending unsafe day care,
c. Accidents and hospitalizations
d. Separation from significant attachment
e. homeless
iii. Tough Time Checklist (self report; there’s a caregiver version)
1. High and moderate magnitude; it does not assess any type of sexual abuse or neglect.
Assessing stressors in adolescents and young adults
Young Adults upsetting Times Checklist
- Includes sexual abuse
Assessing the traumatic characteristics of stressful events (each stressful event is unique)
a. Dimensions of Stressful Events (DOSE)
Assessing emotional responses to HMS
i. Interviews- Did the child’s response involve intense fear, helplessness, or horror, etc.
1. Child and Adolescent Psychiatric Assessment (CAPA: There’s also PAPA and YAPA)
2. Children’s PTSD Inventory (CPTSDI)
a. Quick and detailed
ii. Self-report Questionnaires – if you must use a questionnaire or interview is not possible
1. Exposure questionnaire (EQ)
2. Children’s Peritraumatic Experiences Questionaire (CPEQ)
Assessing ASD (dissociation or derealization)
- Assessing ASD w/ a general psychiatric interview
a. Children’s Interview for Psychiatric Syndromes (ChIPS)
b. Assesses both ASD and PTSD - Assessing ASD w/ a caretaker report of ASD
a. Child Stress Disorders Checklist (CSDC) - ASD Self Report
a. Acute Stress Checklist for Children(ASC-Kids)
Assessing PTSD
a. Preschool children
i. Levonn (cartoon –based studctured interview)
1. DSM DIAGNOSIS NOT POSSIBLE.
b. School-age children and older
i. Clinician-administered PTSD Scale for Children and Adolescents (CAPSCA)
1. Gold standard interview for childhood PTSD.
2. However, takes a while to admin
3. Psychometric properties unknown
ii. Children’s PTSD Inventory (CPTSDI)
1. Good psychometric properties
2. Short to admin.
PTSD- Specific child paper and pencil self reports
a. Posttraumatic Symptom Inventory for Children (PT-SIC)
i. Based on DSM IV criteria
ii. Questions are read to child
iii. Psychometric prop still not proven
b. Child Posttraumatic Stress Reaction Index (CPTS-RI)
i. Most frequently used outcome measure in research on childhood PTSD.
ii. Cannot make diagnosis
iii. Does not assess full range of DSM IV symptomology.
c. UCLA PTSD Reaction Index (UPRID) for DSM IV
i. Parent version available
d. Child PTSD Symptom Scale (CPSS)
i. Psychometrics impressive
ii. HMS assessed
Assessing children’s PTSD w/ caregiver reports
a. Those associated with the CAPA are among the best and most useful.
b. Childhood PTSD Interview –parent form
i. Semistrucutred interview
ii. Allows DSM IV criteria to be assessed and diagnosis to be made.
c. Parent Report of the Child’s Reaction to Stress (PRCRS)
Assessing Complex PTSD
Self-report assessment of complex PTSD among preschool children
a. Angie/Andy Cartoon Trauma Scales
i. Use cartoons for small children
ii. Modeled on the Levonn
b. Structured interview for Disorders of Extreme stress Not otherwise specified (SIDES)
Medications
Moodstabilizers -lithium anticonvulsant -depacoat antipsychotic -abilify
Protective factors
temperament..
outgoing, positive in mood, adaptive to change and higher intelligence.
Parenting factors
Children’s reaction closely related to reaction of caregivers
Hypothalamic pituitary adrenal axis (HPA)
hippocampus (learning and memory)
prefrontal cortex
amygdala
*changes in brain development structure and function…e.g. cortisol levels depleted, neuroendocrine system highly sensitive to stress.
