Transcript Ptsd: Alternatives for a better CHILD FOCUSED DIAGNOSIS?
Creating Connections to Shining Stars
Virginia Beach 17 July 2012
Jane C. Probst, MSW Rappahannock Rapidan Community Services Child & Family Clinical Services
Overview
Expanding Perceptions of Trauma Childhood Trauma: Early Lessons Last a Lifetime Diagnosing Childhood Trauma: DSM IV Criteria Existing Diagnoses Trauma Researcher’s DSM V Proposals - Thinking Differently DSM V Considered Diagnoses Changes – May 2013 Why Diagnoses Matter Adverse Childhood Experiences Study (ACE) ACE Adult Findings ACE Co-Morbid Groups Childhood into Adulthood Outcomes Find Your ACE Score - PDF Score Sheet Why Diagnoses Don’t Matter Considering Trauma Treatment References & Recommended Readings Questions & Comments
Expanding Perceptions of Trauma
Natural Environment Traumas
Hurricanes, Earthquakes, Volcanoes, Floods, Fires - Random
Transportation Traumas
Vehicular Accidents: Land, Sea, Air - Random
Community Violence
Terrorist Attacks - Random War, Ethnic & Cultural Discrimination – Time and place specific
Personal Violence
Stranger Danger, Assaults, Robbery, Sexual Assault/Rape – Random
Interpersonal Violence
Domestic Violence, Partner Abuse, Intimate Partner Violence Occurs within the context of a relationship and is time-relative
Attachment Trauma and Early Childhood Trauma
Age of onset of trauma & trauma symptoms are inversely correlated The younger the age of onset, the more complex the cascade of symptoms
Actually, on a cellular level, I’m very busy…
Infants are born with their fully developed & largest sensory organ – skin! And ready to receive the initial stimulus to begin building neural connections.
Childhood Traumas: Early Lessons
What is Attachment and Attachment Trauma?
Secure or Insecure Attachment, Internal Working Model Mother/primary caregiver is infant’s whole world Reciprocal & symbiotic self-regulate emotions & return to homeostasis Infants 1 st job is to regulate body temperature and functions at birth AT is chronic, accumulative, and compromises learning “Inversely related to the age of onset of first trauma, such that those with early life trauma are more likely to manifest” and accumulate symptoms throughout the lifespan. (van der Kolk et al., 2005)
Natural trauma survival response options in “limbic animals”
Fight: infant has no physical power over abuser Flight: source of safety is source of abuse/neglect place child in a double bind Freeze – only option available to infants & children Restricted brain development & integration in “freeze” state; flooding & restriction of hormones Lesson learned to numb – set up for later maladaptive coping Pronking – exhilarated leaping into the air when contact with predator avoided Defensive mechanism, warning to others of danger, exhilaration at survival
Polyvagal Theory 10 th NS (Porges, 2011)
cranial nerve: evolution of Sympathetic & Parasympathetic
Emotional & physiological regulation synchronized with internal organ regulation Bidirectional signals: 80% afferent (incoming) 20% efferent (outgoing).
Childhood Traumas: Early Lessons
Birth to 18 m. predominate right hemisphere development
Implicitly learned recognition: facial features, tone of voice, incidental environmental cues Incidental verbal/non verbal cues to the safety/danger from caregivers & environment Earliest implicit memories form outside awareness and become hard-wired Mirror neurons reciprocate all emotions, not just 6 we’re born with Teaches emotion and self-regulation simultaneoulsy Neurons that fire together, wire together (Hebbs, 1949) The initial seeds of sympathy and empathy Facial expressions, tone of voice, heart and breath rates model regulation or dysregulation
Diagnosing Childhood Trauma
PTSD: Anxiety Disorder w/Discrete Event – Not a Child Focused Dx
DSM-V change PTSD to Trauma & Stressor Related Disorders – child focused Ignores accumulative layers of chronic trauma, abuse & neglect
Disorder Extreme Stress Not Otherwise Specified - DESNOS
Captures complex trauma symptomatology Not recognized by APA as a diagnosis, however clinicians use it as specifier
Reactive Attachment Disorder
Does not consider trauma outside of attachment with caregivers Many professionals consider it an inaccurate diagnosis > 8 y.o.
Multiple Co-Morbid I, II, III Dx
Diagnostic behaviors are very disorganized & dysregulated; diagnoses difficult ADHD, Bipolar, Conduct Disorder, ODD, Intermittent Explosive Disorder
Accurate assessments for early interventions
Critical learning periods are interrupted/disrupted/mitigated Cascading impairments are accumulative and undeterminable Restricts neural development, accelerates pruning
Researcher’s DSM V Proposals
Developmental Trauma Disorder (van der Kolk, 2005) Comprehensive criteria targeting children Under consideration by APA for DSM V Field trials ongoing ; criteria info at www.traumacenter.org
Disorders of Extreme Stress NOS – DESNOS
Not accepted by APA but used as a ‘qualifier” Can be Co-Morbid with PTSD Diagnosis Different criteria from PTSD
PTSD - Organized Attachment (Classen et al., 2006) Rejected
Caregiver is not the abuser, however, caregiver is not protective Poverty, DV, substance abuse, chronic A & N by others Invisible, Parentified, Secretive Hiding in plain sight
PTSD - Disorganized Attachment (Classen et al., 2006) Rejected
Caregiver is the abuser Significant affect dysregulation Narrow window of tolerance Approach-avoidant behaviors: caregiver is abuser
DSM-V APA Considered Diagnoses
Trauma & Stressor Related Disorders: All Ages
Reactive Attachment Disorder, child is > 9 months
A & N by caregivers, incidental social cues of contempt & disregard
Disinhibited Social Engagement Disorder > 9 months
Multiple caregivers, indicative of children in chronic foster care
PTSD in Preschool Children < 6 years old
Acute Stress Disorder (no age limiting criteria)
Adjustment Disorders
Current subcategories with additions (PTSD/ASD symptoms)
Other Specified Trauma/Stressor Related Disorder
Unspecified Trauma/Stressor Related Disorder
No criteria determined at this time for either of the above
Developmental Trauma Disorder (van der Kolk, 2005)
For diagnoses & criteria info: www.dsm5.org
Why Diagnoses Matter
ATTACHMENT & ATTACHMENT TRAUMA HAPPEN AT CELLULAR LEVEL
Implicit memory begins in utero and is hard-wired Inability of integrated narrative ability – left & right brain integration Restricts critical periods of brain structure development & myelination Stress hormones (cortisol, adrenalin, norepinephrine) flood brain/body Body/brain develop with a baseline of stress hormones Baseline lasts a lifetime without intervention.
Body regulation through CNS is infant’s main job from birth
Identify Dx for prevention, intervention, and treatment Formulation & Implementation of Ethical MH Policies for Children
Attachment Styles are Generational (Hesse, 1999) 75% correlation attachment styles between generations (Schore, 2000) Intervention reduces generational cycles of chronic abuse USDHHS (2002) – identified 870,000 abused/neglected children in US 83.3% abused by primary caregiver Infants to age 3 with highest rates of victimization and death
Research for evidence based treatments
All Axes considered for holistic functioning Mental health: neurobiologically, physiologically, and medically necessary for survival Attachment Theory - Darwin meets Freud!
ACE Longitudinal Study 1998 Kaiser Permanente & CDC
Adverse Childhood Experiences – ACE (n=13,494)
Identified 7 categories of abuse (self-reporting)
Substance abusing family member – 25.6%
Sexual abuse – 22% Mental illness of caregiver – 18.8% Violence against the mother – 12.5% Psychological Abuse -11.1%
Physical Abuse - 10.8%
Family member incarcerated – 3.4%
Poverty & economic risk factors not considered
In depth outcome details: www.acestudy.org
(N=2064)
ACE Adult Findings
Substance Abuse family member exposed to other category
Mental illness of caregiver – 34% Sexual Abuse – 34% Violence against the mother – 29% Psychological Abuse – 22% Physical Abuse – 19% Family member incarcerated – 8%
Violence against mother exposure other category (N=1010)
Substance abusing family member 59% Sexual Abuse – 41% Mental illness of caregiver – 38% Psychological Abuse – 34% Physical Abuse – 31% Family member incarcerated – 10% Witnessed assault with knife or gun – 3% (Felitti et al., 1998)
Groups ≥ 4 of 7 Self-Report
Any combination of 4 or more groups:
Depression for 2 weeks in past year – 50.7%
Illicit drug Use – 28.4%
No leisure time/activity – 26.6%
Suicide attempts – 18.3 %
Smoking - 16.5%
Self identified alcoholic – 16.1%
Obesity - 12%
≥ 50 Sexual partners – 6.8%
STI’s – 6.8%
Childhood to Adulthood Health Outcomes ACE Adult Health Outcomes Studied & Published:
Chronic Disease: Lung Cancer, Heart Disease, Autoimmune Health Risks: Alcohol & Drug Abuse, Obesity, Smoking Mental Health: Depression, Suicidality, Work Absenteeism Victimization & Perpetration: Intimate Partner Violence Sexual Behavior: Fetal Death, Teen Pregnancy, STD’s Autobiographical Memory Disturbances Impaired implicit and narrative memory Special Populations Studies Child Sexual Abuse Victims, Children of Alcoholics, War Refugees
www.cdc.gov/ace/outcomes.htm
Strong Correlations Between Attachment Trauma & PD
75% of BPD are women ( DSM-IV-TR, 2000) w/ history of multiple AT Insecure attachment risk factor for PTSD severity in veterans (Renaud, 2008 )
Finding Your ACE Score
092406RA4CR
While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often…
Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
Yes No If yes enter 1 ________
2. Did a parent or other adult in the household often or very often…
Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
Yes No If yes enter 1 ________
3. Did an adult or person at least 5 years older than you ever…
Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
Yes No If yes enter 1 ________
4. Did you often or very often feel that …
No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
Yes No If yes enter 1 ________
5. Did you often or very often feel that …
You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes No If yes enter 1 ________
Finding Your ACE Score
6. Were your parents ever separated or divorced?
Yes No If yes enter 1 ________
7. Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her?
Or
Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?
Or
Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
Yes No If yes enter 1 ________
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes No If yes enter 1 ________
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
Yes No If yes enter 1 ________
10. Did a household member go to prison?
Yes No If yes enter 1 _______
Now add up your “Yes” answers: _______ This is your ACE Score.
Higher the score, higher the risk consequences of Adverse Childhood Event (Felliti & Anda, 1998) For ACE Score diagnostic tool in Spanish, French, Icelandic, Norwegian, & Swedish http://www.acestudy.org/yahoo_site_admin/assets/docs/ACE_Calculator-English.127143712.pdf
1 st
Why Diagnoses Don’t Matter
Rule - DO NO HARM Constellation of Symptoms = Constellation of Treatments
Individualized with engaged client Sequenced and strength-based Safety, Stabilization, skill building, therapeutic alliance, Trauma processing, narrative integration, meaning of self identity Psycho-education to normalize symptomatology Bottom-up and top-down treatments
Build Therapeutic Alliance Regardless of Diagnoses
Attachment repair, mirror neurons, holding environment Darwin meets Freud!
Affect & Physiological Regulation (physical and emotional regulation) Widen the window of distress tolerance Recounting trauma can re-traumatize – vicarious trauma considerations
Impaired Integration & Transition of Developmental Stages
Implicit memories & narrative abilities - consider developmental age of client Critical learning periods: affect regulation, language, concrete/abstract thinking
Considering Trauma Treatments
Treatment and assessment are ever-evolving
Circling back to crisis & stabilization with newly acquired skills Interventions can be in the moment – trusting the client!
Clinical agility and attunement
It’s never one thing……
Chemical reactions are cascades of reactions & catalysts People are walking talking feeling emoting chemical reactions Emotions are necessary physiological processes dependent on the CNS Treatments focus on outcome may miss the “Lessons Learned”
Developmental age vs. chronological age
Meet the client developmentally Under stress we regress (stunted affect, dysregulated behaviors, etc.) Cyclical groundwork Attachment, Attunement, Alliance & Affect Regulation Trust your client to give you metaphors & analogies
Psycho-education of CNS normalizes trauma sequelae
Panic attacks, nausea, somatization Parasympathetic NS versus Sympathetic NS
Considering Trauma Treatments
Connection & vulnerability – taking worthwhile risks
Simultaneous regulation through combined sequenced therapies
Top-down (cognitive talk-based) & Bottom-up (experiential) therapies Cognitive Processing Therapy – structured 12 sessions includes writing CBT with Prolonged Exposure EMDR – Eye Movement & Desensitization & Reprocessing adults & kids Sensorimotor Psychotherapy – mind/body/spirit (Pat Ogden) Attachment, Self-Regulation & Competency – ARC Margaret E. Blaustein & Kristine M. Kinniburgh (2010)
Experiential learning through repetition rewires brain
Brené Brown www.tedtalks.com
(20 minute video) Neuroplasticity: positive physical activity integrates experiences Procedural memory strengthens (long-term & implicit) Integrate implicit and explicit memories to narrative change of IWM Client is focus, not the trauma
Questions-comments-contributions-insights?
References
Ahrens, J., & Rexford, L. (2002). Cognitive processing therapy for incarcerated adolescents with PTSD. Journal of Aggression, Maltreatment & Trauma, 6(1), 201-216. Axelrod, S. R., Morgan, C. A., & Southwick, S. M. (2005). Symptoms of posttraumatic stress disorder and borderline personality disorder in veterans of Operation Desert Storm. American Journal of Psychiatry, 162, 270-275. Blaustein, M.E., Kinniburgh, K.M. (2010). Treating traumatic stress in children and
adolescents: How to foster resilience through attachment, self-regulation , and
competency. New York, Guilford.
Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965-971. Classen, C. C., Pain, C., Field, N. P., & Woods, P. (2006). Posttraumatic personality disorder: A reformulation of complex posttraumatic stress disorder and borderline personality disorder. Psychiatric Clinics of North America, 29, 87-112. Courtois, C. (2012, February). New Guidelines for the treatment of complex trauma, Chevy Chase, Md.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4). 245-258.
REFERENCES
Heller, D. P. (2012 February) The neurobiology of relationships: Crossing the bridge to secure attachment and to regain resilience and richness in relationships. Washington, DC Hesse, E. (1999). The Adult Attachment Interview: Historical and current perspectives. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (pp.395 – 433). New York: Guilford Press.
Jankowski, M.K., Leitenberg, H., Henning, K., & Coffey, P. (2002). Parental caring as a possible buffer against sexual revictimization in young adult survivors of child sexual abuse. Journal of Traumatic Stress, 15(3), 235 – 244.
Johnson, D. M., Sheahan, T. C., & Chard, K. M. (2003). Personality disorders, coping strategies, and posttraumatic stress disorder in women with histories of childhood sexual abuse. Journal of Child Sexual Abuse, 12(2), 19-39. Jonsson, P. V. (2009). Complex trauma, impact on development and possible solutions on an adolescent intensive care unit. Clinical Child Psychology and Psychiatry, 14, 437-454. Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C., & van der Kolk, B. A. (2001a). Complex trauma and disorders of extreme stress (DESNOS) part one: Assessment. Directions in Psychiatry, 21(25), 373-393.
REFERENCES
Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C., & van der Kolk, B. A. (2001b). Complex trauma and disorders of extreme stress (DESNOS) part two: Treatment. Directions in Psychiatry, 21(26), 395-414. Owens, G. P., & Chard, K. M. (2006). PTSD severity and cognitive reactions to trauma among a college sample: An exploratory study. Journal of Aggression, Maltreatment & Trauma, 13(2), 23-35. Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication , self regulation. New York, W.W. Norton.
Renaud, E. F. (2008). The attachment characteristics of combat veterans with PTSD. Traumatology, 14(3), 1 – 12. Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment & Human Development, 2(1), 23-47 Singer, J. B. (2009). Cognitive-Behavioral therapy. In A. R. Roberts (Ed.), Social worker's desk reference (2nd ed., pp. 742-747). New York: Oxford Sobel, A. A., Resick, P. A., Rabalais, A .E. (2009). The effect of Cognitive Processing Therapy on cognitions: Impact statement coding. Journal of Traumatic Stress 22(3), 205 – 211.
REFERENCES
Spitzer, C., Barnow, S., Wingenfeld, K., Rose, M., Lowe, B., & Grabe, H. J. (2009). Complex post-traumatic stress disorder in patients with somatization disorder. Australian and New Zealand Journal of Psychiatry, 43, 80-86. van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18(5), 389-399. Wesselmann, D., & Potter, A. E. (2009). Change in adult attachment status following treatment with EMDR: Three case studies. Journal of EMDR Practice and Research, 3(3), 178-191. Wolf, G. K., Reinhard, M., Cozolino, L. J., Caldwell, A., & Asamen, J. K. (2009). Neuropsychiatric symptoms of complex posttraumatic stress disorder: A preliminary Minnesota multiphasic personality inventory scale to identify adult survivors of childhood abuse. Psychological Trauma: Theory, Research, Practice, and Policy, 1(1), 49 64.