PTSD and Trauma Related Dxs

Question 1

PTSD
Criteria:

A. Exposure to _____ or ______ death, serious _____, or _____ violence in ___ of the following ways

Name the 4 ways.
For number 4, who counts and who doesn’t count?

if ≤ age 6:
Number 3 must be what?

Answer 1

A. actual or threatened; serious injury; sexual violence; in 1 of the following ways

1. Directly experiencing
2. Witness occurring to others
3. Learning occurred to close other (if actual or threatened death of family or friend must be violent or accidental)
4. Experience repeated or extreme exposure to aversive events or details.

Police and 1st responders count

Exposure through electronic media, TV, etc, do not count unless work related

if ≤ age 6, number 3 “other” must be parent or caregiver

Question 2

PTSD
Criteria:

B. ≥ 1 Sx post trauma

1. Recurrent, distressing _______ (for children it can be __________)
2. Recurrent distressing _________ related to trauma (for children it can be frightening _____ with no recognizable content)
3. ________ reactions/flashback - feels as if trauma _______
   (for children it can be trauma _________)
4. Psychological distress at ______ that ______
5. Physiological distress at _______ that ______

Answer 2

1. memories; children can be repetitive play
2. dreams related to trauma; children it can be frightening dreams
3. Dissociative; trauma reoccurring; children can be trauma play enactment
4. at cues that remind
5. at cues that remind

Question 3

PTSD
Criteria:

C. Avoidance - ≥ 1 Sx post trauma

1. Avoids ______, ______, and _______ reminders
2. Avoids _____, _______, & _________ situations

What are the rules for criteria C and D PTSD < age 6 and how many symptoms do they need?

Answer 3

1. activities, places, and physical reminders
2. people, conversations, and interpersonal situations
3. Combine C (avoidance) with a Revised D (negative cognition/mood) and they only need 1 Sx from combined criteria

Question 4

PTSD
Criteria:

D. Negative Cognition/Mood - ≥ 2 Sxs post-trauma

1. Unable to remember _________ of trauma
2. Persistent ______ ______ (self, other, world)
3. Persistent distorted ideas re: trauma’s _______ or ______ leads to ________
4. Persistent negative ______
5. Markedly decreased ________/______ in activities
6. Feeling _______ from others
7. Persistently unable to feel __________

for < age 6
Revised Criteria D
Minor modifications, mostly to make Sxs more observable (socially withdrawn vs. feeling detached from others)
Why do they make these changes?

What are the rules for criteria C and D PTSD < age 6 and how many symptoms do they need?

Answer 4

1. important aspects
2. negative beliefs
3. cause or consequences leads to self-blame
4. emotions (fear, anger, etc.)
5. interest/participation
6. detached
7. positive emotions

for < 6

These changes are made because kids will find it difficult to explain their feelings. Observation is the only way to gather Sx profile.

Combine C (avoidance) with a Revised D (negative cognition/mood) and they only need 1 Sx from combined criteria

Question 5

PTSD
Criteria:

E. Arousal/Reactivity - ≥ 2 Sxs post-trauma

1. _______/_______ w/ little to no provocation
2. _______/________ behavior
3. Hyper-________
4. Exaggerated _______ response
5. _________ problems
6. _______ disturbance

How long must the disturbance last?

It must cause clinically significant _____ or _____ impairment

Not due to the ______ effects of ______ or another ________

What are the changes to Criteria E for PTSD < 6 years old?

Answer 5

1. Irritability/angry outbursts
2. reckless/self-destructive
3. hyper-vigilance
4. exaggerated startle response
5. concentration problems
6. Sleep disturbance

Disturbance must last ≥ 1 month

distress or functional impairment

physiological effects of substance or another medical condition

For PTSD < 6 years old, Criteria E includes:

• temper tantrums when describing angry outbursts
• No Sx regarding reckless/self-destructive behavior

Question 6

PTSD
Subtypes:

With dissociative Sxs - Meets PTSD criteria and has one recurrent or persistent Sxs with one of these forms of dissociation. What are these 2 forms? Describe them.

Answer 6

1. Depersonalization - feeling detached from, and as if one were an outside observer of, one’s mental processes or body.
2. Derealization - Unreality of one’s surroundings (e.g., world around one is experienced as unreal, dream-like, distant, distorted)

Question 7

PTSD
Specifier:

With delayed expression

Explain what delayed expression means.

Answer 7

Full Dx criteria not met until at least 6 months after event (although some Sxs may onset earlier)

Question 8

PTSD:

Trauma-informed care shifts the focus from…

Answer 8

“What is wrong with you?”
to
“What happened to you?”

Question 9

How many people experience trauma during their lifespan and what is the PTSD lifetime prevalence rate?

Answer 9

~50-60% of people experience during lifespan

PTSD lifetime prevalence rate is 7-8.7%

Question 10

What are the characteristics of a person that makes PTSD more likely?

Answer 10

1. Female
2. Increased number of prior traumas
3. Pre-existing psychopathology

Question 11

What environmental characteristic makes PTSD more likely?

Answer 11

The amount of social support. More social support = less likelihood

Question 12

What are the characteristics of an event that make PTSD more likely? There are 3.

Answer 12

1. Physical proximity to trauma
2. Degree of injury/impact
3. Type of trauma (interpersonal and man-made)

Question 13

PTSD
Etiology:

There are a number of biological mechanisms implicated. What are they?

Answer 13

Neurotransmitters - serotonin, GABA, glutamate, noradrenaline

HPA axis reactivity

Question 14

PTSD
Etiology:

How the event is processed in memory makes a difference. How are trauma memories stored differently from normal memories?

Answer 14

Memories of trauma are not time-tagged and they are easily triggered by the environment.

When triggered, the experience comes on in a way that can replicate the initial experience in terms of feeling. This is why individuals with PTSD are consistently trying to avoid triggers of the memory.

Question 15

PTSD
Tx:

Explain Trauma Focused CBT (TF-CBT)

Answer 15

Individuals are exposed to trigger, possibly through virtual reality.

Cognitive restructuring occurs as trauma is processed.

The nonresponse for CBT for PTSD can be as high as 50%

Question 16

PTSD
Tx:

Explain EMDR.
What’s the controversy with EMDR?

Answer 16

Eye Movement Desensitization and Reprocessing

“Unfreezing” traumatic experience by focusing on it

Become aware of negative thinking

Substitute the negative thinking with positive thinking.

Eye movements help people relax enough to think clearly, sort out trauma, and process it more easily. It provides an external stimulus to focus on rather than the trauma memory alone.

Controversy:
What’s crucial in EMDR? Eye movement or exposure?
Almost identical to TF-CBT - exposing self to memory and cognitively restructuring it.

Question 17

PTSD
Treatment Efficacy:

1. TF-CBT = to which other therapy?
2. Which other therapy seems effective but has less data?
3. Anti-depressants (SSRI/SNRIs) are better than what in reducing Sxs? But they are not as good as…?
4. For what kinds of therapy is there promising evidence?

Answer 17

1. EMDR
2. IPT
3. Placebos; not as goo as TF-CBT
4. CAMS (Collaborative Assessment and Management of Suicidality = neurofeedback, yoga, acupuncture, TMS, etc.)

Question 18

PTSD
Tx:

Explain the argument made against exposure therapy (TF-CBT) in “The Evil Hours”.

Which therapy was better for him?

Answer 18

Idea was to categorize PTSD as a learning disorder. The prolonged exposure in TF-CBT included telling story over and over again in presence of therapist - eventually the story loses its traumatic charge and becomes just like another memory.

Interviewee felt like he was connecting more to all of his memories of being in Iraq rather than just the one he was focusing on. He could feel physical changes in his body in a negative way. Focusing on a single traumatic event was inappropriate because he had a multitude of traumas beyond a single episode that was not being addressed.

He tried Cognitive Processing Therapy - which is derived from CBT - where he examined is thoughts about the world and how these impact his feelings. It uses reality testing to see if his beliefs and thoughts about the world were accurate. He found it to be meditative and helpful for him. He felt it allowed to “let sleeping dogs lie”. Similar to DID treatment - should we let the trauma elements exist as they are and allow the client make the choice of exposing themselves to it? He felt TF-CBT was recreating the trauma and was being done TO HIm. This may not be the experience we want to recreate in therapy. We want them to experience control.

Question 19

Acute Stress Dx:

Define this disorder and its duration.

Answer 19

Exposure to actual or threatened death, serious injury, or sexual violation.

It lasts for 3 days to 1 month after trauma.

Pre-PTSD diagnosis as indicated by the time difference. PTSD ≥ 1 month.

Question 20

Adjustment Disorders:

Define Adjustment Disorders.

How quickly do they have to occur after stressor?

What are the different behavioral expressions?

Answer 20

Emotional or behavioral Sxs in response to an identified stressor.

They must occur within 3 months of stressor.

Behavioral expressions:

• With depressed mood
• With anxiety
• Mixed anxiety and depressed mood
• With disturbance of conduct
• With mixed disturbance of emotions and conduct
• Unspecified

Question 21

Adjustment disorders were once considered what? Hint: They were subclinical.

What’s different about them now?

Answer 21

V-code disorders.

They are diagnosable disorders now but they aren’t as fleshed out as other disorders. There’s fewer diagnostic criteria. This is the hallmark of disorders that were once in the back of the book as V-code disorders but have not yet assumed the status of the other full disorders.

Their main use is when people don’t quite make the criteria for PTSD but have had symptoms for too long to have Acute Stress Dx.

Question 22

Reactive Attachment Dx (RAD) and Disinhibited Social Engagement Dx:

What do both of these Dxs have in common?

Answer 22

Both of these involve the child being exposed to a history of insufficient care (neglect, unable to form stable attachments) responsible for a certain pattern behavior.

Question 23

Reactive Attachment Dx (RAD) and Disinhibited Social Engagement Dx:

What’s different about these Dxs?

Answer 23

Children with RAD are inhibited, emotionally withdrawn, and fearful of non-threatening adult caregivers. Children with DSE have little reticence towards unfamiliar adults and are intrusive.

RAD children do not seek or respond to comforting They have minimal to no interest in caregivers. DSE kids do very little checking with caregivers before exploring and lack appropriate social and physical boundaries.

RAD kids have limited positive affect. They have episodes of unexplained irritability, sadness, or fear around familiar caregivers. They have minimal social and emotional responsiveness. DSE kids willingly and unhesitatingly go off with strangers and are attention seeking (sometimes aggressively). They act overly familiar with strangers, often to a point that it makes adults uncomfortable.

Question 24

Disinhibited Social Engagement Dx:

What intellectual disorder do you have to distinguish DSE from?

Answer 24

Williams Syndrome - an intellectual disorder where child tends to be highly verbally engaged with strangers but less physically engaged as kids with DSE

Question 25

Reactive Attachment Dx (RAD) and Disinhibited Social Engagement Dx
Treatment:

Enduring and emotionally available attachment figure who is…3 things

Answer 25

1. Sensitively attuned to the child
2. Emotionally invested in child
3. Provides a sense of felt security

Question 26

Reactive Attachment Dx (RAD) and Disinhibited Social Engagement Dx
Treatment:

Working with both caregiver and child, the goal is to help the caregiver…2 things

Answer 26

1. Have positive interactions with the child

2. Deal with their own feelings (anger, frustration, etc) that will make them less emotionally available to the child

Question 27

Reactive Attachment Dx (RAD) and Disinhibited Social Engagement Dx
Treatment:

Describe the Circle of Security and its results.

Answer 27

From attachment theory and research: Children need to be able to go out and explore the world but then are able to come back to a secure caregiver whenever they are read. They feel safe going out, feel safe coming in, and feel safe in their care.

“Good enough” theory from Winnicot in Object Relations: better not to be the perfect parent. It allows the child to see that they are not one, not fused together, so there is developmental independence in the child’s understanding. The child is met when necessary wanted to a degree that isn’t always, but mostly, as developmentally appropriate.

Results: Improvements in parenting behaviors and security of child attachment.

Question 28

Dissociative Dxs:

What are the three dissociative disorders?

Answer 28

1. Depersonalization/Derealization Dx
2. Dissociative Amnesia Dx
3. Dissociative Identity Disorder

Question 29

Dissociative Dxs:

Is all dissociation pathological?

Answer 29

Some of it is normative. Not remembering the drive home is dissociating - it’s not integrating the full breadth of your experience at the expense of one other part of your experience.

For traumatic experiences, compartmentalization can occur because individuals cannot feel a certain thing in a certain moment due to some danger (perceived or real) and have to feel the feelings of the event later (think soldier in active battle situation). But if we’re repeatedly exposed to situations where we can’t take the time to feel and process and the dissociation or compartmentalization goes on for too long, it can become pathological. It becomes non-adaptive as the context changes and the person is no longer experiencing a threat, but they still haven’t processed their feelings.

Question 30

Dissociative Dxs:

Define dissociation

Answer 30

Disruptive uncoupling of the normally linked psychological processes. It lakes subjective integration of memory, identity, consciousness, awareness of environment and awareness of the body.

Question 31

Dissociative Dxs:

What are the positive Sxs of dissociation?

Answer 31

Unwanted experiences intrude upon a person’s normal functioning (i.e. flashbacks)

Question 32

Dissociative Dxs:

What are the negative Sxs of dissociation?

Answer 32

Inability to access information or mental processes as one normally would (i.e. deficits in memory, inability to control one’s body)

Question 33

Depersonalization/Derealization Dx
Criteria:

A. Persistent or recurrent experiences of ________, ________, or both

Answer 33

depersonalization; derealization

Question 34

Depersonalization/Derealization Dx:

Define depersonalization

Answer 34

Experiences of unreality, detachment, or being an outside observer of one’s own thought, feelings, sensations, body or actions (Distorted sense of time, unreal or absent self, numbing)

Question 35

Depersonalization/Derealization Dx:

Define derealization

Answer 35

Experiences of unreality or detachment with respect to one’s surroundings (individuals or objects experiences as unreal, foggy, visually distorted)

Question 36

Depersonalization/Derealization Dx:

Does reality testing occur during states of depersonalization and derealization?

Answer 36

Yes. The real you is still doing whatever it’s doing and it’s understood that a perceptual disturbance is occurring during this state

Question 37

Depersonalization/Derealization Dx
Basic info:

Prevalence
Onset
Course
Perceptual

Answer 37

Prevalence: Avg 1.2%
Onset: Late adolescence/early adult
Course: For 2/3rd - chronic
Perceptual: Client’s often describe dissociation as disturbing and ego-dystonic

Question 38

Dissociative Amnesia
Criteria:

A. Inability to recall _________ info, usually of a ______ or _______ nature, that is ________ with ordinary forgetting

note: can be ______ or _______ amnesia for a specific event
OR
_______ amnesia for identity and life Hx

Not better explained by _____, ______, _______, _______, _________

Answer 38

important autobiographical info; traumatic or stressful nature; inconsistent with ordinary forgetting

localized or selective
OR
generalized

Not better explained by DID, PTSD, acute stress Dx, somatic Sc Dx, Major or Mild Neurocognitive Dx

Question 39

Dissociative Amnesia
Specifier:

With dissociative fugue

Describe dissociative fugue

Answer 39

Apparently purposeful travel or bewildered wandering. Associate with amnesia of identity or other important autobiographical info

Only occurs in the presence of Dissociative Amnesia or DID
Fugue specifier prevalence - .2% to 6%

Overall prevalence of Dissociative Amnesia in general is 1.8-7.3%.

Question 40

Dissociative Dxs:

For what reasons in a person’s Hx might they dissociate?

Answer 40

PTSD or prior trauma

Question 41

Dissociative Identity Dx (DID)
Criteria:

A. Disruption of _______ characterized by ≥ 2 distinct _________ which may be described in some cultures as an experience of _________

Involves marked ______ in sense of ______ and self _______ accompanied by related ______ in _______, behaviors, consciousness, _______, _______, cognition, and/or sensory-motor functioning

Note: These signs and Sxs may have been observed by ______ or reported by _______

Answer 41

identity; personality states; possession

discontinuity; self; agency; alterations; affect; memory; perception;

others; individual

Question 42

Dissociative Identity Dx (DID)
Criteria:

B. ____ _____ in the ______ of everyday events, important personal info, and/or traumatic events that are __________

C. Sxs cause _______

D. Disturbance _____ a normal part of a broadly __________ or ________

Note: In children, the Sxs are not attributable to ________ or other ______

E. Not due to ______ (e.g., _______) or a general _____ condition (complex partial _______).

Answer 42

B. Recurrent gaps; recall; inconsistent with ordinary forgetting

C. distress or functional impairment

D. not; accepted cultural or religious practice

Note: imaginary playmates; fantasy play

E. substance; blackouts; medical condition; complex partial seizures

Question 43

Dissociative Identity Dx (DID)
Basic Info:

Prevalence
Suicide Risk
Percentage with alters

Answer 43

Prevalence: 1-1.5%

Suicide Risk: 70% of outpatients with DID have attempted

Alters: 5-15% clearly observable alter switches

Question 44

Dissociative Identity Dx (DID)
Alters:

What are the 2 different kinds of ways an individual with DID can be aware of their alters?

Answer 44

Partial exclusion: Perceptions of hearing voices but voices have an “as if” quality and the person is aware they are not real.

Full exclusion - time loss, fugues

Question 45

Dissociative Identity Dx (DID)
Normative versus Disorder:

How do the boundaries between aspects of the average person’s personality differ from an individual’s with DID?

Answer 45

There are multiple components to every individual’s personality and those components are usually very fluid; we can switch between them with ease and control and they flow into each other. Individuals with DID have very strong borders between alters. They cannot go between parts of themselves with any control. The aspects of their personality and alters are developing almost independently. Fluidity between segments is not there as it is with normative individuals. Some segment might get stuck developmentally and never progress.

Question 46

Dissociation Etiology
Psychodynamic:

Dissociation used to _______ & ________ overwhelming affect related to traumatic events

“Buys” short term _________

Problems arise when ________ used because it leaves ________ unprocessed (in visual, nonverbal, sensory states) that can later intrude on _________

Answer 46

detach and compartmentalize;

resiliency;

habitually used; memories unprocessed; consciousness

Question 47

Dissociative Dxs
Treatment:

Phased Psychotherapy Tx Model is the standard of care

What are the components of Phase 1 - working on safety issues?

Answer 47

• Containment of substance issues and self-injurious behaviors
• Re: trauma: coping/containment mechanisms
• psychoeducation
• Establish therapeutic alliance and improving supportive relationships
• managing dissociative Dx role in overall identity

Question 48

Dissociative Dxs
Treatment:

Phased Psychotherapy Tx Model is the standard of care

What are the components of Phase 2 - processing of trauma?

Answer 48

It’s up to the patient to decide if they want to enter into this phase of Tx. Remember, trauma is something that happens TO a client. We don’t want to recreate this experience in the therapeutic relationship.

• Process trauma to the end of integrating affects previously avoided
• Address cognitive distortions about the event
• Goals are: 1. Person feels mastery over traumatic memories; increased self-efficacy/empowerment and 2. Person feels better integrated

Question 49

Dissociative Dxs
Treatment:

Phased Psychotherapy Tx Model is the standard of care

What are the components of Phase 3 - Life beyond dissociation?

Answer 49

A lot of work has been done by this point and it’s important to ask the client where they want to take therapy at this point. This choice gives them the control that they disorder has not allowed them to have in the past.

• Continued integration of personality states/alters
• Deeper insight into how trauma has impacted relatedness
• Increased focus on attaining life goals and current life issues (live in present)