Topic 8 - PTSD Flashcards
Brief review of diagnosis of PTSD
- First appeared in DSM-III as official diagnosis
- Paradigm shift
- The addition of this diagnosis really Highlighted need for traumatic experience as trigger/truningpoint/cue for stress induced alterations in cognitions, emotions, brain function, as well as behavior.
- The addition of the diagnosis also lead to a lot more research into the impact of trauma – addition of this formalized inclusion of PTSd allowed field as a whole to move forward.
- Up until DSM 3 - researchers were describing a lot of different “syndromes” that now fall under PTSD (abused child syndrome, abused women syndrome, vietnam war veteran syndrome - inclusion of disorder in DSM 3 made syndromes more acknowedlged in one unified category.
- Inclusion association with social movements
- Gross stress reaction in DSM 1 - previously normal people, then had extreme response form stressor.
- When DSM 2 published (during vietnam war) - the whole category was dropped, possibly due to political motivation (political pressure of those in charge of APA then ushered out this potential diagnosis) - even when DSM 2 came out and diagnosis was dropped, researchers still did work on it - edition was called back a year later, new editor said “this has to be included”, going against the political pressure.
- DSM2 –> DSM3 occured most a due to the social movement at the time (as DSM3 was being developed, there was lot of social movement for recognition of veteran sacrifices, and advocacy for feminist groups - part of those advocacies where for recognizing impact of trauma, recognizing impact of trauma that women face from rape, assult, ect - push to recognition of negative traumatic experiences that the groups are facing.) - not clinicians, but general people, wanted the addition of PTSD to DSM3 to happen, and so it did.
- PTSD got more attention and diagnosis in supportof veterans.
- In the DSM III, III-R, IV and IV-TR PTSD was listed under the anxiety disorders category
- Since its official inclusion, the diagnostic criteria have undergone revision and refinement
- 4 criteria in DSM 3: they formed the basis for what we know has as diagnosotic criteria.
- In DSM 3 R: biggest change was that they kinda added and acute and a chronic specifier. Also had additional 2 criteria (now there were 6)
- The DSM-IV saw the addition of Acute Stress Disorder diagnosis
- DSM 4 and 4 TR - refinement on criterion A, splitting it into 2 parts (A1: experiencing, witnessing or being confronted with traumatic event, and A2: person having traumatic experience having intense experience of horror/fear) - also some reshuffling of definitions.
New DSM Category - Trauma- and Stressor-Related Disorders
What we need to know for this slide:
It is a new category, title of category, and there are different disorders beneath it. And that this addition reflects a change in our findings in research, allowing us to think of it as more a trauma based disorder, rather than anxiety TRIGGERED by trauma
Not gonna test on main diagnostic criterion for different disorders.
Reflected a lot of the research: trauma is more than just an anxiety disorder, so it needs its own category, to allow for better understanding and research in the area.
- Trauma- and Stressor-Related Disorders
- Reactive Attachment Disorder
- Chidlhood disorder generally characterisxed by marked disturbance and inappropriate attachment behavior (these children don’t turn to parent for comfiort)
- Disinhibited Social Engagement Disorder
- Culturally inappropriate and overly familiarity (attachment) to strangers (have to be at least 9 months old) - e.g. Running up to complete stranger for comfort after scraping their knee. - important: CULTURALLY inappropriate (look through cultural lense), and have to be at least 9 months (younger than that
- Posttraumatic Stress Disorder
- Acute Stress Disorder
- 3 days to 1 month after exposure (has to meet criterion A in PTSD)
- Adjustment Disorders
- After 3 months of stressor onset, stopping 6 months after stressor has stopped - biggest challenge around diagnosing is you see identifiable stressor 2 years after, you may say its not the adjustment disorder, but it might be because stressor is not done.
- An adjustment disorder is an emotional or behavioral reaction to a stressful event or change in a person’s life. The reaction is considered an unhealthy or excessive response to the event or change within three months of it happening
- Other Specified Trauma- and Stressor-Related Disorder
- When you can clearly see they are showing some kind of symptoms, but don’t quite meet criteria
- Unspecified Trauma- and Stressor-Related Disorder
- when there is some sort of symptom going on you can relate to trauma (e.g. Hyperarousal), but it doesn’t quite fit (feeling like 2 categories e.g.)
DSM-5 criteria for PTSD:
Criteria A
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
◦ Directly experiencing the traumatic event(s).
◦ Witnessing, in person, the event(s) as it occurred to others.
◦ Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
◦ Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
◦ Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
A2 in DSM 4 (immediate/intense feeling of fear/horror) was NOT continued into DSM5 - because it was very weakly predictive of develpment of PTSD - things like anger and shame were just as predictive. People who were A2 positive or negative = no impact on PTSD prevalence (at 6 monhs). = A2 wasn’t helpful, and if you HAD to meet A2 you might not receive diagnosis, even if you rightfully “deserved” it.
DSM-5 criteria for PTSD:
Criteria B
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
◦ Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
◦ Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
◦ Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
◦ Note: In children, there may be frightening dreams without recognizable content.
◦ Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
◦ Note: In children, trauma-specific reenactment may occur in play.
◦ Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
◦ Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
There were some clarifications in DSM 5 (e.g. On rumination and intrusive memories)
Highlighting intrusive memories are DIFFERENT from rumination.
Criterion B was mostly retained, but there was fine-tuning of meaning, and dsitinction between intrusive memories and rumination.
DSM-5 criteria for PTSD:
Criteria C
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
◦ Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
◦ Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Big change form DSM 4 to 5:
We have behaviorally based avoidance symptoms (e.g. Distressing memories, avoidance of external reminders)
Before this there was some mood based stuff in C in DSM 4, they divided in 5 (what is now criterion D)
DSM-5 criteria for PTSD:
Criteria D
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
◦ Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
◦ Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
◦ Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
◦ Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
◦ Markedly diminished interest or participation in significant activities.
◦ Feelings of detachment or estrangement from others.
◦ Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Take aways: change from 4 to 5: split into 2 categories, so we have separate C and D categories now (for mood (D) and avoidance (C))
DSM-5 criteria for PTSD:
Criteria E
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
◦ Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
◦ Reckless or self-destructive behavior.
◦ Hypervigilance.
◦ Exaggerated startle response.
◦ Problems with concentration.
◦ Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
DSM-5 criteria for PTSD:
Combined overview
A: exposure (direct or indirect) to trauma
B: intrusion symptoms (e.g. nightmares)
C: avoidance
D: cognitive/mood alteration symptoms (e.g. bad memory, negative thoughts)
E: alteration in arousal/activity (e.g. hypervigilance)
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
- To allow for normal recovery to occur (allows for symptoms to build, peak and move down)
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
The DSM has specifiers.
There is a delayed expression - renamed of “delayed onset” - subprodromal levels? Lowkey ptsd levels can later accelerate into full blown ptsd symptoms.
There is also a seperate criteria for children 6 years and younger - a lot fo DSM stuff are based on someone’s verbal ability to tell us about thier thoughts, feelings, etc, which in a young child (even adolescents) is harder.
Psychological theories of PTSD – what should a good theory do?
- Good theories should address three consistent research findings
- Address the phenomenology of PTSD
- Should be able to address what PTSD LOOKS like, in terms of symptoms
- Account for the natural course of posttraumatic reactions as well as for those who do not recovery or take longer to recovery
- Most survivors will experience a reduction in symptoms naturally after 3 months, but some people will develop chronic PTSD - what mechanisms underlie this natural recovery process, and what interfere with it? - good theory should account for this.
- Account for efficacy of various CBT based interventions in reducing PTSD symptom severity
- Good theory should account for why some interventions work
Horowitz (1976, 1986) theory of PTSD
• Psychodynamically informed
• Horowitz was psychodynamically based - his theory is really psychodynamically informed, meaning he stressed e.g. Supression, individual’s “world” which is psychodynamically driven
• Argued that when faced with trauma
• Initial response is “outcry” at the trauma
• Basically a normal traume response
• Second is to try and assimilate new trauma information with prior knowledge
• So many people then experience this information overload right after the trauma occurs, they try to assimilate all this info - in this overload, they can’t match info with meaning they had before the trauma
• –> psychological defense mechanisms come into play - trnalsates into e.g. Avoidance of memories - slows extent to which trauma is recalled. HOWEVER the avoidance is slowing process.
• There is also need to integrate new info (from after trauma) with old info (prior to trauma) - this new knowledge will come into mind through intrusive nightmares, etc - these intrusions give opportunities to reconcile the old and new info.
Two processes in the reaction to trauma:
- defense, surpressing the trauma, protection
- Trying to integrate info (pre and post trauma)
• This occurs switchingly/person goes back and forth until trauma intensity decreases (information is integrated, so intensity goes down. - if this goes on in PTSD, they keep going back and forth, they never really integarte, to don’t have the automatic recovery (maybe their defense mechanisms are too strong, so they can’t integrate)
Horowitz Tried to look at how recovery might involve significant cognitive changes
Horowitz was one of first to look at horror/trauma’s impact on wider beliefs (about self, society)
Conditioning theories
- Conditioned stimuli
- Unconditioned Stimulus i.e. the trauma
- Instrumental conditioning
Conditioning theories are basically early theories of what PTSD entail.
Proposed that classical and instrumental (aka operant) conditoning could explain PTSD
Conditioning theory is based on idea of fear and anxiety.
The fear in PTSD is thought to develop through dissociation between a neutral stimulus becomes conditioned.
Instrumnetal conditoning comes into play when we think about avoidance and how it links to PTSD.
Reduces distress, and does that because in avoidance, you escape from the emotional trauma related thing you are trying to escape.
PTSD: the fear associated with PTSD are developed through association with neutral (conditioned) stimulus with unconditioned stimulus - you avoid the trauma directly (unconditioned), or something reminding you of trauma (conditioned)
Criticisms:
How does exposure create a “reset”? = not easily explained by conditioning theory.
Also theory was not all-inclusive = pieces were missing = hard for interventions, for that you kinda need to adresss and components and reduce symptoms.
Conditioning theory for CAUSE of PTSD and MAINTENANCE of PTSD - if you weren’t facing ALL OF THE STRESSOR, you still maintain PTSD (you don’t get exposure to all of it)
We know exposure theories WORK, from conditioning theory, if you’re exposed to them it should decrease over time (so PTSD wouldn’t develop from this theory) - but addition to theory (i think): so you wouldn’t see this natural recovery because you are not exposed to the ENTIRETY of trauma because you avoided some of it - through INTERVENTION you are exposed to entire emotional basket.
Kean and Barlow (2002) theory - Ideological model of PTSD
Grew out of conditoning model, but embeeded in barlows wider model of psychopathology
- Central to the theory
- Biological vulnerability
- Vulnerability to experiencing intense negative affective states + difficulty distinguishing between true and false alarm - mostly genetic
- Acquired psychological vulnerability
- Future oriented mood states characteristized by hypervigilance, and cognitive bias towards threat
In applying this to PTSD, authors hypothesized that exposure to trauma in people with these vulnerabilities, triggers a “true” alarm (unconditioned response) (this is to be expected in face of trauma), and these individuals then experience “learned alarms” (conditioned response) in response to cues associated with traumas - these learned alarms triggers anxious apprehension (“on edge”, awaiting things to go wrong)
(this theory BUILDS ON conditioning theories)
This theory does seem to explain some aspects of PTSD, but criticism:
DOES address fear, but does not explain the GENERALIZATION of fear seen in PTSD (in comparison to phobia, getting generally fearful, rather than fear applying to specific things)
Also doesn’t explain WHY (exposure based) interventions work.
Fear and anxiety play role in PTSD, but other emotions do too, and theory doesn’t address this.
Emotional Processing Theory (Foa & Kozak, 1985, 1986)
Was developed to explain anxiety disorders and developed to explain how the process of exposure therapy works, and why we get the outcomes we do.
Since it came out, it has been adapted to fit PTSD, and account for other emotions that come into play.
Two Premises
Emotional disorders reflect presence of pathological emotion structures
• This structure is in MEMORY, incl representation of emotional stimuli, responses, and meaning associated with emotional stimuli and responses, and the associationg AMONG these representation
• PATHOLIGICAL structures are in memory, they are attached to memory - these emotional structures are part of memory, and include representation of stimuli tied to emotions (e.g. Siren triggers fear, hearing siren is enough to turning on the memory system, which then leads to some problems )
• Really think about it as a memory puzzle, each memory is associated with some emotional outcome - each of the pieces of the puzzle can be turned on, but as soon as one is turned on, they ALL get turned on.
• Pathological = the response is not helpful (when associations between the pieces don’t accurately depict the world - if we think the world is overall a dangerous, the siren going by will trigger idea that the whole world is dangerous - you will start triggering things that are harmless, which will make you think the world is dangerous.
Successful treatment modifies the pathological representations
• If you can’t turn emotion structure on, you can’t modify it.
• A person’s guilt can be challenging (you might think you should have done XYZ)
• This second premise has two conditions that have to happen:
• Emotion structure MUST be turned on (if you don’t have emotion reaction, can’t do shit)
• If person’s thinks they should have done something different, you can challenge that thought (but WHAT could you have done)
• also exposing someone can help decrease symptoms because there is kind of this realization they are gonna get through it, it will end - CHALLENGING THE EXPECTED NEGATIVE OUTCOME, and being able to “ride along” with the negative emotion, and knowing it will be okay/ OR negative emotion doesn’t happen all together. - avoidance is key in PTSD, and making people NOT avoid something is important in treatment.
• What does it mean by word “information that is “incomfatible (???) must be challenged” - so the person’s thoughts and epxlanations, the view they hold, must be challenged, e.g. Veterans thinking they were responsible for what happened - that information doesn’t fit the reality
•
Also hypothesizes fear structures of survivors with PTSD include
• The world is completely dangerous
• Self is totally incompetent
• Dysfunctional cognitions underlie PTSD
• First conition: world is dangerous
• Second cognition: self in competent (I can’t handle ANY stress)
Over time, emotional processing theory has been expanded. Provides good explanantion of development of PTSD and natural recovery process (natural recovery occurs by daily life by repeated activation of trumatic memory, by reahcing out to peers, you are exposing yourself to fears, riding out the pathological structtures.)
Limitation in theory: it focuses on consequence that is “numbing”, but doesn’t explain HOW they come to be (DON’T GET THIS)
Cognitive Theory (Ehlers & Clark, 2000)
• Central tenant
• Result of appraisals related to impending threat
Two key processes
Individual’s appraisals of the traumatic event and/or consequences
• Those with PTSD process traumatic event and consequences of it, that results in a continued sense of current threat - so trauma is in the past, but their thoughts are as if the trauma is ongoing.
• The cognitive theory emphasizes threat-view impact, viewing world as dangerous, self as incompoetent - ongoing threat-relevant appraisals can be about what happens during or after traume, and appraisals are basically about what people can verbally say, and because of this, you can directly challenge them
• causal role of NEGATIVE cognitions, viewing world as dangerous, viewing self as incompetent. - emphasis individual’s accesible, reportable beliefs. Treatment can then directly challenge those.
Nature of the traumatic memory and its integration with other episodic memories
• It is done so in a way that leads it to being ongoing, rather than a past thing.
• when memory is recalled, it feels like it is happening NOW (because it is not very well developed)
These two proceses basically “happen”, and because of this, cognitions make it seem like the trauma is ongoing.
Schema Theories
• Schemas are core beliefs that guide perception and interpretation of information
Common assumptions
• Traumatic events usually contradict existing assumptions (I personally think this would be e.g. believing the world is safe – then getting mugged – experience contradicts schema of a safe world)
• Processing a traumatic experience requires modification of existing assumptions
Initial conceptualisation using schema theory had 2 weaknesses:
- Did not adress factors directly related to developing PTSD, were more general
- Might not account for someone who ALREADY hold a negative world view. (their beliefs were basically confirmed, but went on to develop PTSD) = schema theory didn’t account for this situation
