Suicide Workshop Flashcards
The common responses to Traumatic Events differentiate between Normal (inc. transient) vs. Pathological (esp. chronic) disturbances. What are the common symptoms of psychological distress in initial month(s)?
Common symptoms:
- shock, disbelief, fear, heightened anxiety
- sadness, low mood
- sleep and appetite disturbances
- guilt, anger, grief/ bereavement
- confusion, fatigue
Exposure to potentially traumatic events (PTEs) necessary but NOT sufficient to induce pathological stress syndromes. What is the rough rate of people who adaptively adjust to trauma exposure?
Majority ( > 80%) of people adaptively adjust to trauma exposure
Note: 50-75% of adults exposed to at least 1 PTE in their lifetime. 56% of 15-16 yr olds had 1 PTE. > 60% of teens in USA
YET - Important NOT to pathologize transient stress responses
What are the 4 prototypical patterns/ trajectories of trauma reactions?
1) Chronic Dysfunction = Psychopathology for > 3 mths and up to many years (fluctuating course)
2) Delayed Reactions = Tends to begin as subthreshold PTSD which gets worse overtime
3) Recovery = ‘A trajectory in which normal functioning temporarily gives way to threshold or sub-threshold psychopathology. For a period of several months and then gradually returns to pre-trauma levels’.
4) Resilience = Maintaining relative stable and healthy functioning
Expland on the risks for childhood ‘maltreatment’
physical neglect &/or abuse; emotional abuse (‘hidden’); sexual abuse
Neglect = failing to give a child the care needed according to his/her age & development, e.g., left alone for many days; responsible for taking care of siblings
Emotional abuse = ‘acts as having a high probability of impairing a child’s health or physical, mental, spiritual, moral or social development’ e.g., belittling, denigrating, threats, verbal hostility, ignoring
Sexual abuse: wide array of behaviours PLUS behaviours may be abusive even if they do NOT involve contact, e.g., genital exposure, exploitation for pornography
Domestic Violence (DV) = witnessing vs. exposure
Complex trauma – multiple, prolonged traumas. Usually inclusive of maltreatment elements
What else apart from PTSD is in the new category: ‘Trauma- and Stressor-Related Disorders’
ASD, PTSD & Adjustment Disorders.
Also,
Reactive Attachment Disorder (childhood);
Disinhibited Social Engagement Disorder (children)
What qualifies as ‘Potentially Traumatic Events’ (PTE) for PTSD via Criterion A?
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the 4 following ways:
1. Directly experiencing the event(s)
‘include, but limited to: war (combatant or civilian), threatened or actual sexual violence or physical assault, kidnapping, hostage, torture, POW, natural or human-made disasters, severe MVAs.
* Caveat for medical illness: Medical incidents that qualify as traumatic events involve sudden, catastrophic events (e.g., waking during surgery), anaphylactic shock).’
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or friend. In cases of actual or threatened death, the event must have been violent or accidental. E.g. unexpected events inc. violent personal assault, suicide, serious accidents & serious injuries.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s). [e.g., first responders, repeated exposure to child abuse].
Criteria B is about Re-experiencing the symptoms. What are the 5 possible criterion that people need to meet 1 of?
- B1: intrusive distressing recollections of trauma
- B2: dreams associated with trauma
- B3: dissociative reactions (e.g. flashbacks)
- B4: Intense psychological distress on exposure to trauma-related cues.
- B5: Physiological reactivity on exposure to trauma cues.
Criteria C is about the Persistent Avoidance symptom. What are the 2 categories that people need to meet 1 of?
C1: Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the trauma
C2: Avoidance of or efforts to avoid external reminders (people, places, conversations, etc), that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event
Criterion D is about the Negative alterations in cognitions & mood associated with the trauma beginning or worsening after the event. What are the 7 symptoms that people need to meet 2 of?
D1: Traumatic amnesia – inability to recall an important aspect of the trauma
D2: Persistent & exaggerated negative beliefs or expectations about oneself, others or the world (eg ‘I am bad’, ‘no-one can be trusted’, ‘the world is dangerous’).
D3: Persistent, distorted cognitions about the cause or consequences of the event that lead the individual to blame self or others.
D4: Persistent negative emotional state (e.g., fear, horror, anger, guilt).
D5: Markedly diminished interest or participation in significant activities
D6: Feelings of detachment or estrangement from others.
D7: persistent inability to experience positive emotions.
Criterion E is about Physiological Arousal & Reactivity, and people need 2 out of 6 criteria. Note: PTSD is associated with sustained increased SNS activity – well beyond its adaptive function in response to a traumatic event.
E1: Irritable behaviour and Anger outbursts
E2: Reckless or self-destructive behaviour
E3: Hypervigilance
E4: Exaggerated startle response
E5: Concentration problems
E6: Sleep disturbances
Note about other criterion:
Criterion F: Duration: Symptoms > 1mth
Criterion G: Impairment in functionality
Criterion H: not due to physiological effects of a substance or medical condition.
Specifiers:
with Dissociative symptoms
with Delayed expression (at min 6-months post-trauma)
What are some of the ways the criterion is different for child PTSD?
- Criterion A can be witnessing event occur to others – especially caregivers and learning that the event occurred to a parent or caregiving figure.
- Criterion B - for younger children these memories may not necessarily appear distressing and may be expressed as play re-enactment. Recurrent distressing dreams may not be possible to establish that
frightening dream content is related to trauma. - Criterion C & D: these criterion are combined and child only needs 1/6.
How does trauma specifically impact children?
Functional Disturbances:
Social functioning: difficulties with peers &/or family
Educational functioning
Developmental functioning: regressive behaviours
Common mental health & behavioural problems post-trauma: Sleep problems, Irritability, anger & aggression, Concentration & memory problems, Hypervigilance, Depression, General anxiety, Separation anxiety, Development of specific trauma-related fears.
Effects preschool (tantrums, opposition, aggression, new unrelated fears), primary school and adolescents (awareness of mortality, guilt, substances) differently.
What are some developmental considerations about trauma effecting children?
(1) Encoding the event
(2) Emotion regulation
(3) Cognitive inhibition
(4) Memory retrieval
(5) Language and conversations
What are some risk factors for developing PTSD?
Female gender Psychiatric history (esp. previous trauma) Adverse childhood Low education/ IQ Peri-traumatic experiences dissociations physiological arousal emotions (anxiety, fear etc) Trauma severity Younger age Quality of social support (post-trauma) Coping strategies Additional life stressors (post-trauma)
What are some specific risk factors for developing PTSD in children?
Preschool: mother’s mental health, family social support, maternal-child attachment
Primary school/adolescents: low social support, pre-trauma fear, perceived threat to life, social withdrawal, psychiatric comorbidity, poor family functioning, coping strategies (distraction/thought suppression)
Acute Stress Disorder (ASD) was introduced to the DSM-IV to serve as a Predictor for PTSD. List some of the criterion:
Note: High proportion (~75%) who meet ASD develop PTSD, however a substantial number of people develop PTSD without prior ASD
- Must satisfy criterion A, traumatic event
- intrusive symptoms
- negative mood
- dissociative symptoms
- avoidance symptoms
- arousal symptoms
- symptoms typically begin immediately post-trauma
BUT must persist for at 3 days – and up to 1 month
An Adjustment Disorder is the development of emotional or behavioural symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor. AD stressors may be single event OR multiple stressor! May be the response to a physical illness. What are the other criterion:
B. These symptoms or behaviours are clinically significant as evidenced by one or both of the following:
1. Marked distress that is in excess of what would be expected from exposure to the stressor (taking into account cultural factors)
2. Significant impairment in social or occupational (academic) functioning
C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a pre-existing mental disorder.
D. The symptoms do not represent normal Bereavement.
E. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.
+ Specifiers (with depressed mood/anxiety/disturbance of conduct etc)
What do trauma victims commonly report with?
- mood disorders, anger management, relationship problems, poor sleep, sexual problems,
- physical health complaints - headaches, gastrointestinal, rheumatic pains, skin disorders
Screening for PTSD with a screening tool is useful because you can ‘provisionally screen for’ and acknowledge traumatic history. (note - NOT diagnostic). What are some screening tools?
Trauma/ PTSD Checklists for Criterion A:
- At least 7 different measures (b/w DSM-IV and DSM-5 criteria) e.g., Traumatic Stress Schedule, Traumatic Life Events Questionnaire, Stressful Life Events Screening Questionnaire. Aim is to see if person exposed to a PTE meets criteria for
a) ASD/PTSD - must satisfy Criterion A
b) Adjustment & other affective and mood disorders beyond Criterion A (or both)
Life Events Checklist for DSM-5:
- Three formats of the LEC-5 are freely available: self-report to establish if an event occurred + extended self-report to establish worst event if more than one event occurred + Interview to establish if Criterion A is met
Primary Care PTSD Screen for DSM-5:
Five yes/no questions like “Have had nightmares about the event/s or thought about event/s when you did not want to? YES/NO”
What are some things on the Life Events Checklist for Criterion A? (note: if Crit A is met, you can continue the screening process)
Criterion A screening –
- Natural disasters (e.g., flood, hurricane)
- Fire or explosion
- Transportation accident (car, boat, plane)
- Serious accident work, home, recreationally
- Exposure to toxic substance (e.g., radiation, dangerous chemicals)
- Physical assault (hit, slapped, kicked, beaten up)
- Assault with weapon (shot, stabbed)
- Sexual assault (rape, attempted, sex via force/coercion)
- Combat or exposure to war zone (military or civilian)
- Severe human suffering (torture)
- Sudden violent death (homicide, suicide)
- Life threatening medical condition
- Serious injury, hard, death caused to others
- Sudden unexpected death of loved ones
What information should you collect when doing an assessment of PTSD?
- Trauma History: Details of event/experience(s) & reactions at time of event & how they feel now
- Presence, severity and course of PTSD symptoms
- Presence, severity and course of comorbid problems (especially substance use, depression inc. self-harm, social anxiety, GAD, panic disorder)
- Physical health impairments
a) Any injuries due to trauma event
b) Health behaviour changes post-trauma
c) Development of health problems (or exacerbation of pre-existing)
d) Medication usage (current & past) [prescribed vs. non-prescribed] - Pre-trauma, past & current psychosocial functioning
- Interpersonal relationships (romantic, family, friends, professional)
- Occupational
- Role functioning (self-care, diet, lifestyle)
- Activities engaged in (socially, drinking etc) [now vs. past vs. pre-trauma]
- Goals [now vs. pre-morbid]
- Changes in personality since event - Broader quality of life:
a) Current physical health
b) Marital and family situation – quality of relationships (positive, supportive vs. aversive, constraining, critical)
c) Current work status
d) Financial status (secure/non-stressed)
e) Legal issues (compensation-seeking, trial pending – e.g., rape)
What is involved in making a PTSD diagnosis?
Australian PTSD guidelines recommend multifaceted approach:
- Unstructured clinical I/Vs (primary settings)
- Structured clinical I/vs
- Validated Self-report inventories
- Additional sources: reports from others
There is no ‘gold’ standard interview for comprehensive assessment, but usually involves an unstructured clinical interview (assessing symptoms on intensity and frequency), with diagnosis guided by objective validated diagnostic interviews & instruments. Note: objective assessment recommended if client is involved in medico-legal system
Validated Self-Report Measures:
- Foa’s PTSD Symptom Scale (PSS) (copyrighted)
- PCL-5 (20 items) – Freely available and commonly used in conjunction with LEC
- Davidson Trauma scale
What are some recommended assessment instruments?
Broader Quality of Life Scales:
[e.g., WHOQOL; SF-36; WHODAS]
Dysfunctional Beliefs:
a) Posttraumatic Cognitions Inventory (PTCI)
b) World Assumptions Scale (WAS)
Coping Strategies:
- E.g., COPE/ BCOPE
Comorbid symptom severity:
- BDI-II (depression) (copyrighted)
- BAI or STAI (anxiety) (copyrighted)
- DASS – distress (Australian norms; Free to use)
- Screening for Substance use (e.g. AUDIT)
What are some child measures to use?
PTSD Diagnosis: Child Screening
Traumatic Events Screening Inventory [TESI-C]
Clinician Interview & Parent Report
CAPS- Child version for DSM5
Measures validated pre-DSM-5:
Children’s Posttraumatic Stress Scale (Foa et al., 1996) (8+yrs)
Children’s revised Impact of Event Scale (Perrin et al., 2004)
