PTSD Flashcards
DSM-5 PTSD
Traumatic Event
+
*Intrusive thoughts, recurrent memories, images
- Hyperarousal
- Avoidance
- Mood/ Cognitive Symptoms
- **Changes in cognition and mood new to DSM-5
Hyperarousal and Reactivity
Irritable behavior and angry outbursts
*with little or no provocation
Reckless or self-destructive behavior
Hypervigilance
Exaggerated startle response
Problems with concentration
Sleep disturbances
e.g. difficulty falling or staying asleep, or restless sleep
Intrusive/avoidance behavior
Related to behavior that is similar to the traumatic event
But is usually generalized
Changes to mood/cognitions
New perceptions that the world is less-trusting and (s)he is more vulnerable than originally believed
Includes depression, anxiety, shame, fear, and anger
A combination of strong, negative, emotions
One-Trial Learning
It is the only disorder that requires an event-based prerequisite – i.e. trauma
But only requires one specific (traumatic )event
in contrast to learning theory
Acute stress disorder
A common prerequisite to PTSD, experienced by most people
Only a few are unable to overcome this and then develop PTSD
Dx: 3 days to 1 month
PTSD: Loss of Anxiety
In rare cases, PTSD involves a complete loss in the ability to experience anxiety
Think as if the anxiety-producing systems are “burned-out”
Some argue this burn-out is what leads to suicidal behavior
• These individuals are trying to feel something
May explain adrenaline junkies
PTSD considerations: The Iraq and Afghanistan Wars
The next large-scale military conflicts post-Vietnam
20% - 40% of all soldiers display PTSD-like behavior
• Up to 1 million cases
• Estimated cost of treatment: $750 billion
• Includes treatment, disability, and lost wages
Includes secondary trauma
• Such as therapists developing PTSD after hearing multiple cases of traumatic moments
Why the elevated PTSD rates?
• Desperate need of soldiers lead to the use of those who are inappropriate to serve, such as the National Guard
Actions in the war often did not make the front page – little national support/attention
As well as a new restriction of showing military action in the media
Aggression and violent behaviors are addicting and pleasurable
o However the consequences are traumatizing
Suicide rates in military veterans with PTSD
Drastic increase over the past 15 years
Typically the suicide rate of this population is smaller than the civilian rate
Has since become significantly higher
More soldiers now die via suicide than in combat
From 2005 to 2011, service members have killed
themselves approximately once every 36 hours. For
veterans, the rate is estimated at once every 80
minutes.
PTSD: Development
Most individuals simply develop acute stress disorder, which eventually fades
• So who develops PTSD?
A previous diagnosis of an anxiety disorder increases one’s chance of developing PTSD
Those with PTSD typically do not discuss underlying emotions of the trauma
Soldiers and law enforcement officers are specifically trained not to discuss individual expression and/or emotions
• These individuals, therefore, need to be “retrained”
Those who hid or fail to act out against a traumatic event tend to feel worse than those who do act out in an attempt to stop it
o e.g. the man who fails to subdue an active shooter
o e.g. the woman who fails to fight off a rapist
Tonic mobility is a natural response to extreme anxiety – it’s a defense mechanism
• But the consequences may include PTSD
Treating PTSD
Goal: address the underlying anxiety
Target narrative of the trauma and the client’s role during the event
PTSD does not arise simply from experiencing a trauma
• It stems from one’s reaction (physically and mentally) and interpretation of the trauma
Treating PTSD: Gender Considerations
For males: PTSD often arises due to a violation of providing, protecting, or procreating
For females: PTSD can arise for failure to protect children
Women are significantly more protective of their children than men
DSM 5 PTSD: Specifiers
With dissociative symptoms
• Depersonalization
• Derealization
With delayed expression (if criteria is not met until at least
six months after the trauma)
Prevalence
General Population:
10% of men and 20% of women exposed to a TE will
develop PTSD
Factors associated with increased
risk of PTSD in combat veterans
Multiple deployments
Chronic stress (no safe zone)
Close combat (urban warfare)
Lack of social support (does anyone really care?)
Course
Most recovery from the symptoms that emerge after traumatic events occurs in the first three months after the trauma
Early severity of PTSD symptoms is the best predictor of the development of chronic PTSD
Once PTSD becomes a chronic disorder, there is little
spontaneous recovery
*PTSD patients may have periods of symptom reduction largely because the person has organized his/her life around avoiding reminders of the event
Post Traumatic Stress Reaction
An evolutionary prepared alarm system?
Direct and vicarious conditioning to dangerous
stimuli leads to avoidance of that stimulus –
including cognitive avoidance
Avoidance becomes conditioned way to reduce the
anxiety (negative reinforcement)
One-trial conditioning
PTSD: Pathological reaction??
GUILT/SHAME
Perceived responsibility
Perceived insufficient justification for actions taken
Perceived violation of values
Perceived preventability/foreseeability of negative
outcomes
Addressing the Traumatic Memory
2 Primary Psychotherapeutic Strategies
1) Prolonged Imaginal Exposure
The traumatic memory(s) typical primary emotion: fear (danger - threat to one’s life)
2) Cognitive Therapy
* post-trauma appraisal of personal response during the trauma
* appraisal of one’s self post-trauma
Secondary emotions depend upon the nature of the appraisal
Recommendation for Sequencing Treatments
CBT First
or
Combination of CBT + medication
(not medication alone)
Therapeutic Style:
Basic ingredients are essential with PTSD
Let the patient tell his/her “story”
don’t intervene too quickly!
Establish supportive relationship
we will get you through this together
Validation – self-disclosure
that is horrible: I’d be terrified too! I can’t even imagine being in a situation like that
Provide control and decrease vulnerability: reassure that tx will go at his/her own pace
*Therapists - be aware of secondary traumatization
Phase I: Psychoeducation: Understanding PTSD
General facts about PTSD: when is it a disorder?
Dispel myths about PTSD (weakness)
Discuss the cognitive behavioral model of PTSD
Discuss the components and rationale of CBT
Phase II. RELAXATION STRATEGIES
Respiratory Control
Slow, deep, diaphragmatic breathing (8-12 breaths per minute) is taught to help reduce and control symptoms of anxiety
RATIONALE: decrease hyperventilation and accompanying physical sensations of fear (e.g., heart rate).
IN SESSION: practice to be certain patient correctly uses this coping skill
HW: Practice twice daily for at least 10 continuous minutes – not when anxious
Phase II. RELAXATION STRATEGIES
Progressive Muscle Relaxation
RATIONALE: decrease hyperarousal
IN SESSION: practice to be certain patient correctly
employs the skill
HW: Twice daily – approx 15 minutes
Phase III. Imaginal Exposure To Traumatic Event
Goal is habituation and processing
Similar to stress inoculation
Extinguish the associations between the thoughts/
images and anxiety/fear
Prolonged exposure–> anxiety reduction is secondary to habituation
Start with eyes open if that’s more comfortable, for only a couple of minutes, build toward eyes closed and longer duration
*don’t be too forceful that they won’t proceed
Guidelines for Conducting Imaginal Exposure
Trauma scene relived in imagination, patient asked to
describe it aloud (present tense).
Therapist should guide this by “setting the scene”
- What did you see?
- How did you behave? Others?
- What were you thinking?
- How were you feeling?
- What did you fear would happen?
- Additional: smells, sounds, etc.
Then move to next scene. And so on.
Phase IV: Cognitive Restructuring
Cognitive restructuring involves an extended, systematic
effort to:
Educate about role of thoughts and beliefs in causing or maintaining emotional distress
Identify distressing thoughts and beliefs
Discuss, review evidence, and generate alternative cognitions to:
(1) correct distortions (e.g., over-responsibility, unrealistic
expectations)
(2) facilitate acceptance when appropriate (“war is hell”).
Mechanism of Action: Cognitive Reprocessing
Impact of the trauma alters the individual’s belief system
For the trauma memory to become integrated, it requires incorporation into an existing cognitive schema or developing new schema
How does the trauma redefine the individuals sense of self?
Exposure, general
Exposure isn’t to trauma, but to stimuli that have been generalized from fear associated with trauma
e.g. enclosed spaces like movie theatre or restaurant after violence experienced on a train
PTSD treatment: keys to success
Show compassion
Validate experiences
Normalize behavior, cognitions, and emotions
PTSD is often an existential crisis We need to redefine the client’s image of him/herself in order to allow for the treatment to succeed
Resistance / Attitudes
Attitudes held by soldiers may interfere with processing:
e.g.
Be a man
Be a warrior
Don’t show emotion
You should just get over it
