Trauma

Describe Reactive Attachment Disorder

• Dx criteria (7)

• Tx

Dx Criteria:

• Consistent pattern of inhibited, emotionally withdrawn behavior toward caregivers; as indicated by BOTH:

  • Child rarely/minimally seeks/respond to comfort when distressed

• Persistent social/emotional disturbance; As indicated by 2:

  • Minimal social/emotional responsiveness to others

  • Limited positive affect

  • Episodes of unexplained/unprovoked irritability, sadness, or fearfulness 

• Child experienced extremes of insufficient care; as indicated by ONE:

  • Social neglect of deprivation:

    • Caregivers = not meeting child’s emotional need 

      • (comfort, stimulation, affection)

  • Repeated changes of Caregivers

    • Limit opportunities forming stable attachments 

  • Rearing in unusual settings that limit severely limit selective attachments

• Disturbance is evident before age 5; Child has developmental age of at least 9 months

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Treatment

• Basic medical care

• Provision of adequate caretaking

• Parent education/psychiatric treatment

• Legal intervention 

• Ongoing psychotherapy interventions

Describe Disinhibited Social Engagement Disorder

• Dx criteria (7)

• Tx

Dx Criteria:

• Behavior pattern where child act. approaches/interacts w/ strangers; as indicated by TWO:

  • Reduced/absent reticence in approaching/interacting w/ strangers

  • Willingness to go w/ stranger w/o hesitation 

  • Overly familiar verbal or physical behavior 

  • Diminished/absent checking back w/ caregiver after venturing away

• Child experienced patterns of insufficient care; indicated by ONE:

  • Social neglect of deprivation 

  • Repeated changes of caregivers

  • Rearing in unusual settings

•  Child has developmental age of at least 9 months

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Tx:

• Provision of adequate caretaking

• Parent education/psychiatric tx

• Child will need ongoing psychotherapy interventions with adult caregivers

Describe PTSD

• Dx criteria

• Management

Dx Criteria:

• Exposure to actual/threatened death, serious injury, or sex. Violence in ONE:

  • Directly experiencing event

  • Witnessing (in person) event

  • Learning that close friend/family affected by event

  • Experience repeated/extreme exposure to aversive details of event

• Presence of intrusive symptoms associated w/ event; as indicated by ONE

  • Recurrent/involuntary/intrusive distressing memories of event

    • May be repetitive play in children

  • Recurrent distressing dreams of the event

    • Children: nightmares w/o recognizable content

  •  issociative reactions (e.g. flashbacks) where pt feels/act as if event were recurring

    • Children: trauma-specific reenactment may occur in play

  • Intense prolonged psychological/physiologic distress at exposure to cues resembling event’s aspects 

• Persistent avoidance of stimuli associated w/ event; evident by ONE:

  • Avoidance of distressing memories, thoughts, or feelings associated w/ event

  • Avoidance of external reminders that arose distressing memories/thoughts/feelings of event

    • (people, places, conversations, activities, objects, situations)

• Negative alterations in cognitions/mood associated w/ event; indicated by TWO:

  • Inability remembering important aspect of event

  • Persistent/exaggerated negative beliefs/expectations 

    • Oneself, others, or the world

  • Persistent, distorted cog about cause/consequences of event -> blame themselves

  • Persistent negative emotional state

  • Markedly dim interest/participation in significant activities

  • Feelings of detachment/estrangement from others

  • Persistent inability to experience positive emotions

• Marked alterations in arousal/reactivity; as indicated by 2:

  • Irritable behavior and angry outbursts

  • Reckless/self-destructive behavior

  • Hypervigilance

  • Exaggerated startle response

  • Problems with concentration

  • Sleep disturbance

• Duration >1 Month

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Management

• First-line

  • SSRI’s and SNRI’s

  • Group therapy

  • Family therapy

  • CBT/ Prolonged exposure therapy

    • Correct cognitive distortions

    • Controlled exposure for avoidance

    • Imaginal therapy

• Second-line

  • Benzodiazepines

  • Prazosin (nightmares and hypervigilance)

    • Becoming first-line treatment

• Experimental

  • Stellate ganglion block in military PTSD

How does these work:

• Prolonged Exposure Therapy

• EMDR

Prolonged Exposure Therapy

• Imaginal Exposure

  • Patient recounts traumatic event in detail

  • Therapist helps patient process the memory

• In vivo exposure

  • Gradually confronting real-life situations or places the patient has been avoiding due to trauma

• Duration: 8 to 15 weekly sessions

• Effective for both military and civilian trauma

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EMDR: Eye Movement Desensitization and Reprocessing

• Pt move eyes side to side of follow therapist’s finger

• Pt asked to activate disturbing memory

• Pt identify feelings/cognition about memory, modify irrational cognitions, follow chains of associations to explicate the personal meanings of emotionally charged memories

• Drawback:

  • MOA not clearly established; long-term efficacy not firmly established

  • APA position: needs further study

  • VA and DOD position: “strongly recommended”

Describe Criteria for Acute Stress Disorder

• Dx criteria (4,1,2,2,5)

• Prognosis/Treatment

Criteria for Acute Stress Disorder

Dx Criteria:

• Exposure to traumatic events (same as PTSD)

• Presence of nine (or more) of following symptoms

  • Intrusion Symptoms

    • Recurrent involuntary/intrusive distressing memories of event

    • Recurrent distressing dreams of event 

    • Dissociative reactions (e.g. flashbacks) where pt feels/act as if event were recurring

    • Intense/prolonged psychological/physiological distress/reactions in response to cues (int/ext) of event

  • Negative Mood

    • Persistent inability to experience positive emotions

  • Dissociative Symptoms

    • Altered sense of reality  (oneself/surroundings)

    •  Inability to remember important aspects of event

  • Avoidance Symptoms

    • Efforts to avoid distressing memories, thoughts, or feelings about event

    • Efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about event

  • Arousal Symptoms

    • Irritable behavior and angry outbursts,

    • Sleep disturbance

    • Hypervigilance

    • Exaggerated startle response

    • Problems with concentration

• DURATION: 3 days - 1 month (max)

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Prognosis/Treatment:

• 80 % progresses to PTSD

• Tx: 

  • Relaxation training

  • Short course of benzodiazepine

  • Possible beta-blockers