Trauma and PTSD Lecture Notes

Poly-Victimization

  • Definition: Experiencing multiple victimizations involving different types of abuse, bullying, and exposure to family violence.
  • Emphasis: Focuses on different kinds of victimization rather than repeated instances of the same type.
  • Occurrence: Typically happens during transitional phases when children are most vulnerable.
  • Association: Linked to adverse life circumstances like domestic violence, distressed families, violent neighborhoods, or mental health problems.

Complex Trauma and Impairment

  • Poly-victimization can lead to complex trauma, resulting in:
    • Attachment Problems:
      • Issues with boundaries
      • Distrust and suspiciousness
      • Social isolation
      • Interpersonal difficulties
      • Difficulty attuning to others' emotional states and perspective-taking
    • Biological Problems:
      • Sensorimotor developmental issues
      • Analgesia
      • Problems with coordination, balance, and body tone
      • Somatization
      • Increased medical problems like pelvic pain, asthma, skin problems, autoimmune disorders, and pseudoseizures
    • Affect Regulation Difficulties:
      • Difficulty with emotional self-regulation
      • Difficulty labeling and expressing feelings
    • Dissociation:
      • Distinct alterations in states of consciousness
      • Amnesia
      • Depersonalization and derealization
      • Two or more distinct states of consciousness
      • Impaired memory for state-based events
    • Behavioral Control:
      • Poor impulse modulation
      • Self-destructive behavior
      • Aggression toward others
      • Pathological self-soothing behaviors
      • Sleep disturbances
      • Eating disorders
      • Substance abuse
      • Excessive compliance
      • Oppositional behavior
      • Difficulty understanding and complying with rules
      • Reenactment of trauma in behavior or play
    • Cognition:
      • Difficulties in attention regulation and executive functioning
      • Lack of sustained curiosity
      • Problems processing novel information
      • Problems focusing on and completing tasks
      • Problems with object constancy
      • Difficulty planning and anticipating
      • Problems understanding responsibility
      • Learning difficulties
      • Problems with language development
      • Problems with orientation in time and space
    • Self-Concept:
      • Lack of a continuous, predictable sense of self
      • Poor sense of separateness
      • Disturbances of body image
      • Low self-esteem
      • Shame and guilt
      • Problems knowing and describing internal states
      • Difficulty communicating wishes and needs

Trauma and PTSD: Chowchilla Kidnapping

  • Date: July 15, 1976
  • Location: Chowchilla, California
  • Victims: 26 children aged 5-14 on their way to school.
  • Incident: Three armed men hijacked their bus and abducted the driver along with all the children.
  • Imprisonment: They were held in a buried truck trailer in a quarry.
  • Duration: The bus driver and children were held for 16 hours.
  • Escape: They managed to escape before ransom demands were issued.
  • Outcome: All survived but many suffered from post-traumatic stress disorder (PTSD).

PTSD Symptoms Following Trauma

  • Fears of further trauma
  • Hallucinations
  • "Omen" formation
  • Time skew
  • Posttraumatic symptoms:
    • Posttraumatic play reenactment
    • Personality change
    • Repeated nightmares

PTSD in Children: Omen Formation

  • Definition: The belief that there were signs that predicted the traumatic event.
  • Purpose: Children believe they must be alert at all times to recognize warning signs of future traumatic events to prepare for them.
  • Mechanism: A child misinterprets a coincidental event as a predictive warning, creating a false but emotionally powerful pattern.
  • Reflection: It's the brain’s attempt to find patterns and avoid future harm, even if those patterns are illogical.

PTSD in Children: Time Skew

  • Definition: Incorrect recall of the sequence of the traumatic events.

PTSD in Children: Reenactment of Trauma

  • Post-traumatic reenactment:
    • Play, drawings, or communications representing traumatic experiences.
    • Compulsive nature
    • Does not reduce anxiety
  • Posttraumatic Play:
    • Violent play with a theme similar to what they experienced, but not always.

Posttraumatic Stress Disorder: Traumatic Event (DSM 5)

  • Definition: A psychosocial stressor involving actual or threatened death, serious physical injury, or sexual violation.
  • Nature of Event:
    • Intentional
    • Accidental
    • Natural
  • Proximity:
    • Must occur to the child or a close person.
  • Exclusion: Hearing about it or seeing it on TV does not qualify for PTSD diagnosis.

Post Traumatic Stress Disorder: Diagnostic Criteria (Adults, Adolescents, Children > 6 years)

  • A. Exposure to actual or threatened death, serious injury, or sexual violence in one or more 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 friend, especially if violent or accidental death.
    • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders).
      • Note: Exposure through electronic media doesn't apply unless work-related.
  • B. Presence of one or more intrusion symptoms, beginning after the traumatic event(s):
    • Recurrent, involuntary, and intrusive distressing memories.
      • Note: In children, repetitive play may occur expressing themes of the event(s).
    • Recurrent distressing dreams.
      • Note: In children, frightening dreams without recognizable content may occur.
    • Dissociative reactions (e.g., flashbacks).
      • Note: In children, trauma-specific reenactment may occur in play.
    • Intense or prolonged psychological distress at exposure to cues resembling the event(s).
    • Marked physiological reactions to cues resembling the event(s).
  • C. Persistent avoidance of stimuli associated with the traumatic event(s):
    • Avoidance of distressing memories, thoughts, or feelings.
    • Avoidance of external reminders (people, places, etc.).
  • D. Negative alterations in cognitions and mood, beginning or worsening after the event(s), evidenced by two or more:
    • Inability to remember an important aspect (dissociative amnesia).
    • Persistent and exaggerated negative beliefs about oneself, others, or the world.
    • Persistent, distorted cognitions about the cause or consequences leading to blame.
    • Persistent negative emotional state (fear, horror, anger, guilt, or shame).
    • Markedly diminished interest or participation in activities.
    • Feelings of detachment or estrangement from others.
    • Persistent inability to experience positive emotions.
  • E. Marked alterations in arousal and reactivity, beginning or worsening after the event(s), evidenced by two or more:
    • Irritable behavior and angry outbursts.
    • Reckless or self-destructive behavior.
    • Hypervigilance.
    • Exaggerated startle response.
    • Problems with concentration.
    • Sleep disturbance.
  • F. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.
  • G. The disturbance causes clinically significant distress or impairment.
  • H. The disturbance is not attributable to substance use or another medical condition.

PTSD Specifiers

  • With dissociative symptoms:
    • Depersonalization: Feeling detached from one's mental processes or body.
    • Derealization: Experiences of unreality of surroundings.
      • Note: Dissociative symptoms must not be due to substances or other medical conditions.
  • With delayed expression:
    • Full diagnostic criteria are not met until at least 6 months after the event.

Maltreatment, PTSD, and Dissociative Disorders

  • Repeated Childhood Victimization:
    • Sympathetic (fight and flight) and parasympathetic (flag and faint) nervous system activation (the defense cascade).
    • Repeated oscillation through this cycle and reactions.
    • Dissociative detachment or shutting down may be the most likely way of surviving inescapable threat, leading to the parasympathetic system being more persistently activated.
  • Protective Responses:
    • These may become habitual means of regulating emotion.
    • Viewed as attempts to survive extreme circumstances where fundamental developmental needs are not met.

Affect/Emotion Dysregulation

  • Definition: Problems in managing or recovering from extreme states of emotions.
  • Under-regulation:
    • Limited access to strategies to reduce intense affective states and associated difficulties with impulse control.
  • Overregulation:
    • Non-acceptance and limited awareness or clarity of emotions
  • Impairment:
    • An impaired ability to regulate and/or tolerate negative emotional states

Childhood Abuse and Brain Regions

  • Study: Gold, A. L., et al. (2016). Journal of child psychology and psychiatry, and allied disciplines, 57(10), 1154–1164.
  • Findings:
    • Maltreatment exposure and severity were associated with reduced thickness in prefrontal cortex (PFC), orbitofrontal cortex (OFC), & right inferior frontal gyrus.
    • Left and Right PHG thickness were inversely related to externalizing symptoms.

Limbic System Changes and Childhood Maltreatment

  • Amygdala Responsiveness:
    • Childhood Trauma Questionnaire (CTQ) scores strongly associated with amygdala hyper-responsiveness to threat-related facial expressions.
  • Structural Changes:
    • Reduced gray matter volumes in the hippocampus, insula, orbitofrontal cortex, anterior cingulate gyrus, and caudate in subjects with high CTQ scores.
  • Influencing Factors:
    • Associations were not influenced by trait anxiety, depression level, age, intelligence, education, or more recent stressful life events.
  • Mediators:
    • Adversities during childhood can mediate the development of emotional disorders.