Crisis intervention strategies chapter 7

Chapter 7 - Posttraumatic Stress Disorder

1


MANY CRISES MAY BE ROOTED IN PTSD
1.
2.
3.
4.
5.
6.
7.
8.
9.

Suicide
Substance abuse
Rape
Sexual abuse
Battering
Loss
Physical violence
Hostage situations
Natural and human-made disasters

2


DIAGNOSING PTSD (DSM-IV-TR, APA 2000)
First (see page 152):

* Person Exposed to a trauma/event that involved

actual or threatened death or serious injury, or a threat
to self or other's physical well-being.
* Response is intense fear, helplessness, or horror.
* As a result, has persistent symptoms of anxiety or
arousal that were not evident before the trauma/event.
3


DIAGNOSING PTSD (DSM-IV-TR, APA 2000)
Second (see page 152):
Person persistently re-experiences the traumatic event in at least one
of the following:
*

1. Distressing recollections
2. Nightmares
3. Flashbacks
4. Intense distress from cues that symbolize event
5. Physiologic reactivity from cues

4


DIAGNOSING PTSD (DSM-IV-TR, APA 2000)
Third (see page 152):
* Person persistently avoids such stimuli in at least three
of the following:
1. Thoughts, dialogues, or feelings about trauma

2. Activities, people, or situations about trauma
3. Inability to recall important aspects of trauma
4. Diminished interest in significant activities
5. Feels detached emotionally and socially
6. Numbing feelings
7. Sense of short future

5


DIAGNOSING PTSD (DSM-IV-TR, APA 2000)
Fourth (See page 152)
*

Person has increased nervous system arousal as indicated by at least
two of the following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating on tasks
4. On Watch for real or imagined threats
5. Startle reactions to minimal or non-threatening stimuli

6


DIAGNOSING PTSD (DSM-IV-TR, APA 2000)

Fifth (see page 152):
* Person has clinically significant distress or

impairment in social, occupational, or other
critical areas of living.
* For more than one month.

7


INCIDENCE
* About 8% for general civilians
* About 20% after a trauma
* Higher for at risk groups:
1. Adolescents and young adults
2. People in hazardous occupations
3. Sexual assault victims
4. Severe burn cases
5. Psychiatric cases
6. Refugees
7. War vets can be much higher.

8


WAR VETS - TERMS
1.
2.
3.
4.
5.
6.

Hypervigilance (alert all of the time)
Bonding (unit cohesion)
Debriefing time (adjusting to non-war life)
Guilt (survivors)
Dissociation (numbing or lack of emotional
responsiveness)
Hyperarousal and/or acoustic startle response

9


5 MALADAPTIVE PATTERNS OF PTSD
1.
2.
3.

4.
5.

Death Imprint (continuing identity with death and
sensation-seeking behaviors)
Survivors Guilt
Desensitizing oneself to totally unacceptable events, and
then trying to return to a semblance of normalcy in a
peaceful world (bipolar emotions)
Estrangement (from relationships and/or social services)
Emotional enmeshment (fixation on trauma keeps them
from successful relationships/family functioning

10

TODAYS WAR VETS/SOLDIERS
1.
2.
3.
4.
5.
6.
7.
8.

13-25% for Mid-East vets
Suicide rate increased
Women and men
Family impact
DOD is more proactive
Better Assessments
Better interventions
Better outreach programs

11


3 COMPONENTS OF PTSD TREATMENT OF ADULTS
1.
2.
3.

Processing and coming to terms with the

experience
Controlling physiological and biological
stress reactions
Reestablishing secure social connections
and interpersonal efficacy

12


3 GOALS IN ASSESSMENT FOR PTSD
ADULTS
1.
2.
3.

Are PTSD symptoms present?
Are drugs or personality disorders masking
PTSD?
How is the event contextually interpreted by
the person?

13


ASSESSMENTS FOR PTSD
1.
2.
3.

Structured Interviews (Clinician-Administered

PTSD Scale - CAPS-1, based on DSM-IV-TR)
Unstructured self-reports (time efficient Traumagram Questionnaire
Emperically Derived Scales (typically
population based)

14


PHASES OF RECOVERY FOR PTSD
1.
2.
3.
4.
5.

•

The emergency or outcry phase (fight or flight)
The emotional numbing and denial phase (avoidance)
The intrusive-repetitive phase (nightmares, volatile mood
swings, intrusive images, etc) - Now seeking help.
The reflective-transition phase (better perspective, coming
to grips)
The integration phase (successfully integrates the trauma
with other past experiences and restores a sense of
continuity to life.
Note: Cycles and trancrisis highly frequent

15

PSYCHOTROPIC MEDICATION
1.
2.
3.
4.

Some relief of psychophysiological
responses
Prozac (antidepressant)
Clonidine (decrease arousal)
Requires careful prescription and monitoring
with expertise

16


GROUP TREATMENT TYPES
1.

2.

Debriefing Groups (preventative, short term
and typically for acute like-distress survivors of
a common traumatic experience)
Support Group (longer term and typically
composed of class-specific members who
have been exposed to the same type of trauma
but at different times and under different
circumstances.)

17


PTSD GROUPS (2 PHASES)

1.
2.

Focus on accessing and working through the
trauma and its symptoms.
Life Adjustment Group - Focus on the
readjustment to contemporary society.
(Behavioral change, coping, family etc.)

18


PTSD AND CHILDREN
1.
2.
3.

US, 30 to 50% will experience at least one
traumatic event by 18th birthday
US, 1 million cases (homegrown) child
abuse per year
Of those with at least one trauma (3-16%
girls, 1-6% boys) will develop PTSD

19


PTSD AND CHILDREN - TYPE OF TRAUMA
1.
2.
3.
4.

100% of children will get PTSD if they see a
parent killed or sexually assaulted
90% of sexually abused children will develop
PTSD
77% of children who witness a school
shooting
35% of children who witness neighborhood
violence

20


PTSD AND CHILDREN - TREATMENT
1.
2.
3.
4.
5.
6.

Depends on developmental stage

and Cognitive ability
Adult diagnosis is not the same (DSMs no
longer captures what fits for children)
Support system is critical
Separation carries emotional and personality
disturbance
Unresolved grieving is a major ingredient to
pathology
21


TYPES OF CHILDHOOD TRAUMA
1.
2.

3.

Current and aftereffects into adulthood have to be
considered
Type I - sudden, distinct traumatic experience
(detailed fully etched-in memories, misperceptions,
mistiming of the event, etc.)
Type II - Long-standing and comes from repeated
traumatic ordeals (psyche's developing defensive
and coping strategies to ward off the assaults such as denial, dissociation, repression psychic
numbing, self aggression etc.)
22


TREATMENT OF CHILDHOOD PTSD

1.
2.
3.

Early assessment is critical
Interviewing helps reduce long-term
symptoms (but parents may be resistant)
Requires great skill with both CogitiveBehavioral Therapy and Play Therapy

23


EMDR (ADULTS AND CHILDREN)
1.
2.
3.

Eye Movement Desensitization and
Reprocessing
Controversial
Requires specialized training

24