Post-Traumatic Stress Disorder (PTSD) Diagnosis and Implications for Treatment and Rehabilitation...
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Transcript of Post-Traumatic Stress Disorder (PTSD) Diagnosis and Implications for Treatment and Rehabilitation...
Post-Traumatic Stress Disorder (PTSD)
Diagnosis and Implications for Treatment and Rehabilitation
Wendy S. David, Ph.D.AER International Conference
Psychosocial Division
July, 2012
Overview of Presentation
Trauma and PTSD Sexual Assault Violence and Abuse Against People
with Disabilities Treatment Interventions
Examples of Traumatic Events
Interpersonal violence Violent criminal acts Disasters (natural, manmade) Accidents Military combat Witnessing of death and handling of
body parts
PTSD DiagnosisCriterion A stressor
Symptom Criteria Re-experiencing Symptoms (1 of 5 ) Avoidance/Numbing Symptoms (3 of 7) Hyperarousal (2 of 5)
Symptoms are unbidden, cause subjective distress, and impair psychosocial functioning. Duration at least 1 month Chronic PTSD duration > 3 months
Common Comorbidities
Mood Disorders Anxiety Disorders Substance Use Disorders Somatization Disorders Eating Disorders Personality Disorders Complex PTSD or Disorders of Extreme
Stress Not Otherwise Specified (DESNOS)
Associated Features
Disruption of Core Values and Beliefs
Pervasive distrust Damaged self concept Dissociation
Prevalence Rates in General Population
70% of adults in the US have experienced a traumatic event at least once Up to 20% of these people go on to
develop PTSD 17 % of men and 13 % of women have
experienced more than three traumatic events in their lives
Prevalence Rates in General Population (cont.)
5 % of Americans – more than 13 million people – have PTSD at any given time
8 % of all adults – one of 13 people in this country – will develop PTSD during their lifetime
Women are twice as likely as men to develop PTSD (5% male, 10% female)
Nature of Trauma and Estimated Risk for Developing PTSD
Rape (49 %) Severe beating or physical assault
(31.9 %) Other sexual assault (23.7 %) Serious accident or injury; for
example, car or train accident (16.8 %)
Nature of Trauma and Estimated Risk for Developing PTSD (Cont)
Shooting or stabbing (15.4 %) Sudden, unexpected death of family
member or friend (14.3 %) Child’s life-threatening illness (10.4 %) Witness to killing or serious injury
(7.3%) Natural disaster (3.8 %)
Risk Factors for Developing PTSD
Individual: Previous traumatization Prior history of abuse Age Gender IQ Personal or family history of
psychiatric problems
Risk Factors for Developing PTSD (Cont)
Event : Interpersonal violence (especially rape) Chronicity of situation Threat of death
Peritraumatic dissociation Physical, mental, sensory disability
Brief PTSD Screening Tool
In your life, have you ever had any experiences that were so frightening, horrible or upsetting, that, in the past month, you….
1... have had nightmares about it or thought about it when you did not want to?
2…tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3…were constantly on guard, watchful, or easily startled?
4…felt numb or detached from others, activities, or your surroundings?
Cut Score: > 3 - Positive screen for possible PTSD
Facts about Sexual Assault
1 in 6 women; 1 in 33 men (10% of victims)
Girls 4 times more likely than boys 44% under age 18; 80% under
age 30
Facts about Sexual Assault (cont.)
22% drop since 2000 One of the most underreported crimes About 80% committed by someone
known to victim Battery causes more injuries to women
than any other source Firearms involved in about 3% rapes
and sexual assaults
Who is the Perpetrator? 98% men, 95% same race, 20% adolescents Repeat molester: 50 girls, 150 boys 90% know to child (up to 99% for disabled) Need for: power, control, authority Justifies behavior Minimal empathy and personal responsibility Past histories of abuse as children Access
Impact of Sexual Abuse
Mild to severe physical injuries, STD’s, Pregnancy, Death
PTSD, Emotional distress including anger, anxiety and fearfulness
Substance abuse, Depression, low self-esteem, Social withdrawal
Impaired ability to trust Learning difficulties Related disabilities Tendencies toward re-victimization
Consequences of Assault
Rape victims are: 6.2 times more likely to develop PTSD 3 times more likely to develop MDD 4 times more likely to have completed
suicide 13 times more likely to have made a
suicide attempt
Violence and Abuse Against People with Disabilities
54 million disabled Americans 6 million serious injuries each year due
to crime 18,000 children per year permanently
disabled by abuse/neglect Children with disabilities are:
1.6 times more likely to be neglected 2.2 times more likely to be sexually
abused
Violence and Abuse Against People with Disabilities (cont.)
85% disabled women victims of domestic violence (25-50% non-disabled)
Abuse and domestic violence rated as #1 priority issue by disabled women
Women with disabilities are twice as likely than non-disabled women to experience interpersonal violence
1 in 3 VI women and 1 in 3 VI men report being survivors of abuse
Risk Factors for Sexual Abuse in Children With Disabilities
"Show me a child that knows nothing about sex and I'll show you a highly qualified victim." —Gavin de Becker, 1999.
Greater dependency on caregiver. Learned compliance. Fear of retaliation. Restricted circles of friends and
acquaintances.
Risk Factors for Sexual Abuse in Children With Disabilities (cont.)
Lack of information about body boundaries/ownership, abuse, and self-protection
Less understanding of what constitutes "right" or "wrong" behavior
Less able to identify the perpetrator Less able to run and hide Unsure of who to trust or confide in Often not believed
Family Characteristics
Family isolation Disruptions in parent-child attachment Unrealistic expectations of the child Substance abuse leading to chaotic,
overcontrolling environment Family history of violence and/or
sexual abuse
Course of PTSD
40% recover within the first year 1/3 to 1/2 of those with PTSD do
not recover Duration shorter with early
treatment Duration of PTSD varies
according to severity
Efficacy of Psychotherapy How Well Does it Work? Psychotherapy is effective in treating PTSD Magnitude of effect is moderate to very large Effectiveness is sustained over time (follow-up) Effectiveness demonstrated across different
trauma types and clinical populations Changes from psychotherapy are statistically
and clinically meaningful
Stages of Treatment & Recovery
1.Safety and Stabilization
2. Remembrance and Mourning
3. Reconnection and Integration
1.Safety and Stabilization
Psychoeducation about PTSD and process of treatment
Coping Skills development Treatment objectives:
Symptom reduction Increased Tolerance for Trauma
memories and emotions
Maladaptive vs Adaptive Coping Strategies
Maladaptive Coping
Drugs, Alcohol to self-medicate Isolation from friends/supportsStopping formerly pleasant activitiesUsing anger to distance or controlWorkaholic as distraction
Adaptive Coping StrategiesUse of arousal reduction techniquesLimit exposure to media coverageSchedule pleasant activitiesAttend to physical needsReconnect with spirituality
2. Remembrance and MourningTrauma Processing and Mourning Losses
Treatment Objectives: Modify distorted perceptions of traumatic event Modify maladaptive beliefs regarding self and
world Reduce avoidance-based coping strategies and
numbing Regulation of emotions and impulsive behavior Assignment of new meaning to trauma
experience and self as survivor
3. Reconnection and Integration
Establishing and Living a Meaningful Life Work School Family Spirituality Finding purpose
Reconnection and Integration (cont.)
Relapse Prevention Treat Physical Illness Balance Eating Avoid Mood Altering Drugs Balance Sleep Get Exercise Build Mastery
Cognitive Behavioral Treatments
Seeking Safety Cognitive Therapy Assertiveness Training Biofeedback and Relaxation
Training Behavioral Activation
Exposure Treatments
Prolonged Exposure Cognitive Processing therapy Image Rescripting and Reprocessing Self Defense Personal safety: Safe
without Sight & Taking Charge EMDR Systematic desensitization
Pharmacotherapy for PTSD
SSRIs Adrenergic blocking agents: Prazosin Other antidepressants Mood stabilizers Anti-anxiety medications
Caution in using benzodiazepines