Transcript Testing

Post-Traumatic Stress
Disorder (PTSD)
Diagnosis and Implications for
Treatment and Rehabilitation
Wendy S. David, Ph.D.
AER International Conference
Psychosocial Division
July, 2012
Overview of Presentation
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Trauma and PTSD
Sexual Assault
Violence and Abuse Against People
with Disabilities
Treatment Interventions
What is PTSD?
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Anxiety disorder
Terrifying Traumatic Event
Grave Physical Harm/Threat
Examples of Traumatic
Events
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Interpersonal violence
Violent criminal acts
Disasters (natural, manmade)
Accidents
Military combat
Witnessing of death and handling of
body parts
PTSD Diagnosis
Criterion A stressor
Symptom Criteria
 Re-experiencing Symptoms (1 of 5 )
 Avoidance/Numbing Symptoms (3 of 7)
 Hyperarousal (2 of 5)
Symptoms are unbidden, cause subjective
distress, and impair psychosocial
functioning.
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Duration at least 1 month
Chronic PTSD duration > 3 months
Common Comorbidities
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Mood Disorders
Anxiety Disorders
Substance Use Disorders
Somatization Disorders
Eating Disorders
Personality Disorders
Complex PTSD or Disorders of Extreme
Stress Not Otherwise Specified (DESNOS)
Associated Features
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Disruption of Core Values and
Beliefs
Pervasive distrust
Damaged self concept
Dissociation
Prevalence Rates in General
Population
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70% of adults in the US have
experienced a traumatic event at least
once
 Up to 20% of these people go on to
develop PTSD
17 % of men and 13 % of women have
experienced more than three traumatic
events in their lives
Prevalence Rates in General
Population (cont.)
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5 % of Americans – more than 13
million people – have PTSD at any
given time
8 % of all adults – one of 13 people in
this country – will develop PTSD during
their lifetime
Women are twice as likely as men to
develop PTSD (5% male, 10% female)
Nature of Trauma and Estimated
Risk for Developing PTSD
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Rape (49 %)
Severe beating or physical assault
(31.9 %)
Other sexual assault (23.7 %)
Serious accident or injury; for
example, car or train accident
(16.8 %)
Nature of Trauma and Estimated Risk
for Developing PTSD (Cont)
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Shooting or stabbing (15.4 %)
Sudden, unexpected death of family
member or friend (14.3 %)
Child’s life-threatening illness (10.4 %)
Witness to killing or serious injury
(7.3%)
Natural disaster (3.8 %)
Risk Factors for Developing
PTSD
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Individual:
 Previous traumatization
 Prior history of abuse
 Age
 Gender
 IQ
 Personal or family history of
psychiatric problems
Risk Factors for Developing PTSD
(Cont)
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Event :
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Interpersonal violence (especially rape)
Chronicity of situation
Threat of death
Peritraumatic dissociation
Physical, mental, sensory disability
Brief PTSD Screening Tool
In your life, have you ever had any experiences that
were so frightening, horrible or upsetting, that,
in the past month, you….
1... have had nightmares about it or thought about it
when you did not want to?
2…tried hard not to think about it or went out of your
way to avoid situations that reminded you of it?
3…were constantly on guard, watchful, or easily
startled?
4…felt numb or detached from others, activities, or
your surroundings?
Cut Score: > 3 - Positive screen for possible PTSD
Facts about Sexual Assault
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1 in 6 women; 1 in 33 men (10%
of victims)
Girls 4 times more likely than boys
44% under age 18; 80% under
age 30
Facts about Sexual Assault (cont.)
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22% drop since 2000
One of the most underreported crimes
About 80% committed by someone
known to victim
Battery causes more injuries to women
than any other source
Firearms involved in about 3% rapes
and sexual assaults
Who is the Perpetrator?
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98% men, 95% same race, 20%
adolescents
Repeat molester: 50 girls, 150 boys
90% know to child (up to 99% for disabled)
Need for: power, control, authority
Justifies behavior
Minimal empathy and personal responsibility
Past histories of abuse as children
Access
Impact of Sexual Abuse
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Mild to severe physical injuries, STD’s,
Pregnancy, Death
PTSD, Emotional distress including anger,
anxiety and fearfulness
Substance abuse, Depression, low selfesteem, Social withdrawal
Impaired ability to trust
Learning difficulties
Related disabilities
Tendencies toward re-victimization
Consequences of Assault
Rape victims are:
 6.2 times more likely to develop PTSD
 3 times more likely to develop MDD
 4 times more likely to have completed
suicide
 13 times more likely to have made a
suicide attempt
Violence and Abuse Against
People with Disabilities
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54 million disabled Americans
6 million serious injuries each year due
to crime
18,000 children per year permanently
disabled by abuse/neglect
Children with disabilities are:
 1.6 times more likely to be neglected
 2.2 times more likely to be sexually
abused
Violence and Abuse Against People
with Disabilities (cont.)
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85% disabled women victims of
domestic violence (25-50% nondisabled)
Abuse and domestic violence rated as
#1 priority issue by disabled women
Women with disabilities are twice as
likely than non-disabled women to
experience interpersonal violence
1 in 3 VI women and 1 in 3 VI men
report being survivors of abuse
Risk Factors for Sexual Abuse in
Children With Disabilities
"Show me a child that knows nothing about
sex and I'll show you a highly qualified
victim." —Gavin de Becker, 1999.
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Greater dependency on caregiver.
Learned compliance.
Fear of retaliation.
Restricted circles of friends and
acquaintances.
Risk Factors for Sexual Abuse in
Children With Disabilities (cont.)
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Lack of information about body
boundaries/ownership, abuse, and
self-protection
Less understanding of what constitutes
"right" or "wrong" behavior
Less able to identify the perpetrator
Less able to run and hide
Unsure of who to trust or confide in
Often not believed
Family Characteristics
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Family isolation
Disruptions in parent-child attachment
Unrealistic expectations of the child
Substance abuse leading to chaotic,
overcontrolling environment
Family history of violence and/or
sexual abuse
Course of PTSD
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40% recover within the first year
1/3 to 1/2 of those with PTSD do
not recover
Duration shorter with early
treatment
Duration of PTSD varies
according to severity
Efficacy of Psychotherapy
How Well Does it Work?
 Psychotherapy is effective in treating PTSD
 Magnitude of effect is moderate to very
large
 Effectiveness is sustained over time (followup)
 Effectiveness demonstrated across different
trauma types and clinical populations
 Changes from psychotherapy are
statistically and clinically meaningful
Stages of Treatment &
Recovery
1.Safety and Stabilization
2. Remembrance and Mourning
3. Reconnection and Integration
1.Safety and Stabilization
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Psychoeducation about PTSD and
process of treatment
Coping Skills development
Treatment objectives:
 Symptom reduction
 Increased Tolerance for Trauma
memories and emotions
Maladaptive vs Adaptive
Coping Strategies
Adaptive Coping
Maladaptive Coping
Strategies
Drugs,
Alcohol to selfmedicate
Isolation from
friends/supports
Stopping formerly
pleasant activities
Using anger to distance
or control
Workaholic as
distraction
Use
of arousal reduction
techniques
Limit exposure to media
coverage
Schedule pleasant
activities
Attend to physical needs
Reconnect with
spirituality
2. Remembrance and
Mourning
Trauma Processing and Mourning Losses
Treatment Objectives:
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Modify distorted perceptions of traumatic event
Modify maladaptive beliefs regarding self and
world
Reduce avoidance-based coping strategies and
numbing
Regulation of emotions and impulsive behavior
Assignment of new meaning to trauma
experience and self as survivor
3. Reconnection and
Integration
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Establishing and Living a
Meaningful Life
 Work
 School
 Family
 Spirituality
 Finding purpose
Reconnection and Integration
(cont.)
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Relapse Prevention
 Treat Physical Illness
 Balance Eating
 Avoid Mood Altering Drugs
 Balance Sleep
 Get Exercise
 Build Mastery
Therapies for PTSD
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Cognitive Behavioral
Treatments
Exposure Treatments
Other
Cognitive Behavioral
Treatments
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Seeking Safety
Cognitive Therapy
Assertiveness Training
Biofeedback and Relaxation
Training
Behavioral Activation
Exposure Treatments
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Prolonged Exposure
Cognitive Processing therapy
Image Rescripting and
Reprocessing
Self Defense Personal safety: Safe
without Sight & Taking Charge
EMDR
Systematic desensitization
Other
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Marital and Family Therapies
Group Therapy
Psychoeducation/skills training
Pharmacotherapy for PTSD
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SSRIs
Adrenergic blocking agents: Prazosin
Other antidepressants
Mood stabilizers
Anti-anxiety medications
Caution in using benzodiazepines
Points to Remember:
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Stages of treatment dynamic
Best if take small steps
Maximize opportunity for success
“ladder approach”
Build in and maintain structure
Identify potential/real obstacles
Problem-solve creative solutions
“think outside of the box”