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.