Trauma and Stressor Related Disorders

What is trauma?

• Physical Abuse

• Sexual Abuse

• Emotional Abuse

• Bullying

• Witnessing Trauma

• War

• Natural Disasters

What to know about resilience?

• The ability to withstand stress and catastrophe

• Develops over time

• Associated with good self-esteem and positive self worth

• Problem solving builds resilience

• Good communication and coping skills

• Connections and close relationships

• Mindfulness

• Taking care of body-exercise

• Avoid negative outlets-drinking or certain people etc.

• Help others

• Be proactive and have goals

• Accept change

• Maintain a hopeful outlook

• Learn from the past

What to know about posttraumatic stress disorder?

• Affects 3.5% population annually

• 1:11 will experience it at some point in their lives

  • More common in women and symptoms last longer

  • Higher rates among veterans and minorities

What is the PTSD Criteria for Diagnosis?

• Exposure to actual or threatened death, serious injury, or sexual violence either directly as a witness, learning about the events (violent death of family member) or repetitive exposure (first responders

• Symptoms present for more than one month

• One or more of the following symptoms:

  • Recurrent distressing memories or dreams

  • Dissociative reactions (flashbacks)

  • Intense or prolonged psychological distress if triggered or exposed to something that reminds you of the event

  • Marked physiological distress if triggered or re-exposed

• Persistent avoidance of stimuli associated with traumatic exposure

• Negative alterations in cognitions and mood associated with the event

  • Amnesia of the event or aspects of it

  • Persistent and exaggerated negative beliefs about oneself, others, or the world

  • Persistent, distorted thoughts about the cause or consequences of the event

  • Persistent negative emotional state (guilt, shame, fear)

  • Markedly diminished interest in participation in activities

  • Feelings of detachment or estrangement from others

  • Persistent inability to experience positive emotions

• Disturbance causes significant distress or impairment in social, occupational, or other areas of functioning

• Not attributable to physiological effects of a substance

• May be associated with dissociative symptoms.

• Marked alterations in arousal and reactivity associated with the traumatic events

  • Irritable behavior and angry outburst

  • Reckless or self-destructive behavior

  • Hypervigilance

  • Exaggerated startle response

  • Problems with concentration

  • Sleep disturbance

What is the evidence of PTSD in young children?

• Bedwetting

• Regression-quits talking etc

• Acting out the event during play

• Clingy

What are the safety issues for PTSD?

• Increased risk of suicide and suicide attempts

• Increased rates of aggression

• Increased rates of substance abuse

• Increased rates of risky sexual behavior especially in women

What is included in the assessment of PTSD?

• Trauma: how has it affected you, support systems, etc

• Physical health

  • Sleep

  • Pain

  • Other somatic symtoms: GI, etc

• Nutrition

• Medications

• Other mental health conditions

• Suicide attempts or thoughts

• Substance use

• Psychosocial assessment

• Behavioral responses (avoidance, hyperarousal, hypervigilance, etc)

• Self-concept (ie guilt, etc)

• Daily stressors, coping patterns

• Functional status

• Social network and support

What is included in the treatment of PTSD?

• Sleep hygiene

• Exercise and yoga

• Good nutrition

• Smoking cessation

• Medication

• Therapy: individual and group

• Patient Teaching

  • Identify triggers

  • Safety plans for stressful times

  • Risk factors for recurrent symptoms

  • Avoiding substances

  • Community services

  • Keep follow up appointments

• Medications

  • SSRI or SNRI

  • Prazosin for nightmares

  • Some individuals with psychosis, severe dissociative symptoms etc may require 2^nd generation anti-psychotic

• Therapy

  • Trauma focused psychotherapy

  • Group therapy may be beneficial

  • Exposure therapy

  • Stress reduction

  • CBT

What are the other stress disorders?

• Acute Stress Disorder

• Dissociative Disorders

  • Dissociative Identity Disorder

  • Depersonalization/Derealization Disorder

What is dissociation?

• Disruption in the normal integration of memory, identity, emotion, body representation, motor control and behavior

• Occurs along a continuum and some level of dissociation occurs in everyone (daydreaming, zoning out, hyperfocus). 

What is depersonalization/derealization?

• Depersonalization: Experiences of unreality, detachment or being an outside observer of your own body, distorted sense of time, emotional numbing

• Derealization: Experiences of extreme detachment-in a fog, unreal, may have visual distortions.

• Causes significant distress

• Reality testing remains intact

• Not attributed to any other physical or mental health condition

• Time is going to fast or too slow

• Difficulty in recalling some past memories and owning them as your own

• May obsess over whether or not they are real

• May have anxiety and depression

• Hyperreactivity to emotional stimuli

• Mean age of onset is 16

• Flat affect, robotic demeanor

What is the treatment for dissociative disorders?

• Cognitive Behavioral Therapy

• Eye Movement Desensitization and Reprocessing

• Medication (SSRI, etc)

What to know about dissociative identity disorder?

• Disruption in identity characterized by two or more distinct personality states-discontinuity in sense of self, affect, behavior, consciousness, memory, perception, and sensory-motor function

• Gaps in everyday events and memory

• Causes distress

• Not a normal part of a broadly accepted cultural or religious practice or imaginary playmates associated with childhood

• Voice, attitudes, preferences, names, ages etc. may shift back and forth

• Dissociative amnesia

  • Gaps in remote memory

  • Lapses in what happened today

  • Discovery of evidence of task and actions that they don’t remember doing

• Associated with childhood trauma

• Over 70% of outpatients with DID have attempted suicide

• Associated with other mental health disorder

• Functionality is variable

• Impacts relationships, school, job performance etc

• Treatment goal is to reduce anxiety and integrate components of the person

• Medication and therapy

• Hypnosis