Understanding Trauma and PTSD

Criteria A of PTSD

• Exposure to actual or threatened death, serious injury, or sexual violence in one or more

• Subcomponents 

  1. Direct experience 

  2. As a witness as it occurred 

  3. Learning it happened to someone 

  4. Exposure to aversive details

Criteria B of PTSD

• Intrusion Symptoms

  • One or more

    1. Intrusive memories

    2. Nightmares

    3. Dissociative reactions

    4. Similarity cues

       1. Psychological and physiological distress

Criteria C of PTSD

• avoidance symptoms (C 1-2) 

  1. One or both 

     1. Avoid distressing memories, thoughts, feelings about event 

     2. Avoid external reminders (people, places, conversations) of event

Criteria D of PTSD

• Negative alterations in cognition and mood

  • Two or more 

    1. Inability to remember important aspects of event

    2. Negative beliefs about self, others, world after event

    3. Self-blame

    4. Persistent negative emotional state

    5. Loss interest in sig. Activities

    6. Feeling detached from others

    7. Inability experience pos. Emotions

Criteria E of PTSD

• marked alterations in arousal and reactivity

  • Two or more 

    1. Irritable behavior – angry outbursts

    2. Reckless, self-destructive behavior

    3. Hypervigilance

    4. Exaggerated startle response

    5. Problems with concentration

    6. Sleep disturbances

Duration of PSTD vs Acute Stress Disorder

1. Duration 

   1. 1+ month 

2. Acute Stress Disorder 

   1. Less than one month 

Dissociation

• Mental process of disconnecting from one’s thoughts, feelings, memories 

• Trauma perspective - division of self trying to get through daily life, disconnecting from the part of self holding trauma

Depersonalization

• Feeling detached from one’s self thoughts 

• Outside observer thoughts/body, feeling in a dream, time moves slowly, sense of unreality in body (disconnected)

Derealization

Experiencing unreality of surroundings

Delayed expression

criteria not met until 6 months after event

CPTSD Classification

• Not in DSM-V-TR (2022)

• But is in ICD-11 International (2018) Classification of Diseases (WHO)

CPTSD Definition (ICD)

• Chronic, repeated, prolonged exposure to an extremely threatening or horrific event or series of events

• C-PTSD is PTSD + Disturbances of Self-Organization (DSO)

Disturbances of Self-Organization

• emotional regulation

• negative self-concept

• interpersonal disturbances

emotional regulation (DSO)

1. Dysr. autonomic nervous system 

   1. ANS regulates body functions out of awareness

   2. SNS - accelerator

   3. PNS - brakes

What is affect dysregulation (emotional regulation)

• Disruptive overwhelming emotions

  1. High arousal (SNS) anxiety, rage, fear, emotional outbursts

  2. Low arousal (PNS) helplessness, despair

Self-Identity (DSO)

• Struggle to form coherent sense self

• Alteration in system of meaning

• Something is wrong with me

  1. Chronic emotions shame, guilt, despair 

  2. beliefs damaged, worthless, not loveable 

• Existential loneliness

relational capacities (DSO)

• Difficult to trust others

• Fear abuse and betrayal

  1. avoidance with others (disconnect)

  2. over-dependence (fear abandon)

• Difficulty hearing other views and perspectives (need agreement)

During assessment, know the ways a therapist might establish therapeutic safety

• Most Important Goal - Establish Relational Safety 

• Pay attention to social, cultural, developmental factors 

• Ask questions at a pace the client can tolerate

• Use questions to facilitate conversations to build relationship

ACES Study

1. 10 categories of trauma 

2. Link between developmental trauma and problems in adult physical and mental health 

Key Findings of ACES Study

1. Higher ACEs score – higher likelihood disease, physical, and emotional problems in adulthood

   1. >50% at least 1

   2. 25% >/= 2

   3. 17% >/= 4

Know what types of  adult diseases and causes of death are predicted by 4 or more ACEs.

• 4 or more predictive of increased physical and mental health risks 

  1. 1 out of 6 adults 

CAPS-5 (Clinician Administered PTSD Scale)

1. U.S. Department of Veteran Affairs gold standard 

2. 30-items clinical interview 

3. Training required

PCL-5 (PTSD Checklist)

1. 20 self-report items 

2. 1-5 Likert scale 

3. Scores 31-33 probable PTSD

Definition of Window of Tolerance

• Optimal level of nervous system arousal 

  1. Aware of body 

  2. Think clearly 

  3. Express range emotions 

Purpose of Window of Tolerance

• WOT increases as clients develop safety in connection with others

• Can feel threatening

  • May push therapist away

  • Be distrustful

• Compassionate approach

  • View behaviors as survival strategies