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

Trauma and PTSD Sexual Assault Violence and Abuse Against People

with Disabilities Treatment Interventions

What is PTSD?

Anxiety disorder Terrifying Traumatic Event Grave Physical Harm/Threat

Examples of Traumatic Events

Interpersonal violence Violent criminal acts Disasters (natural, manmade) Accidents Military combat Witnessing of death and handling of

body parts

PTSD DiagnosisCriterion 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. Duration at least 1 month Chronic PTSD duration > 3 months

Common Comorbidities

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

Disruption of Core Values and Beliefs

Pervasive distrust Damaged self concept Dissociation

Prevalence Rates in General Population

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.)

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

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)

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

Individual: Previous traumatization Prior history of abuse Age Gender IQ Personal or family history of

psychiatric problems

Risk Factors for Developing PTSD (Cont)

Event : 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

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.)

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? 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

Mild to severe physical injuries, STD’s, Pregnancy, Death

PTSD, Emotional distress including anger, anxiety and fearfulness

Substance abuse, Depression, low self-esteem, 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

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.)

85% disabled women victims of domestic violence (25-50% non-disabled)

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.

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.)

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

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

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 (follow-up) 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

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

Maladaptive Coping

Drugs, Alcohol to self-medicate Isolation from friends/supportsStopping formerly pleasant activitiesUsing anger to distance or controlWorkaholic as distraction

Adaptive Coping StrategiesUse of arousal reduction techniquesLimit exposure to media coverageSchedule pleasant activitiesAttend to physical needsReconnect with spirituality

2. Remembrance and MourningTrauma Processing and Mourning Losses

Treatment Objectives: 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

Establishing and Living a Meaningful Life Work School Family Spirituality Finding purpose

Reconnection and Integration (cont.)

Relapse Prevention Treat Physical Illness Balance Eating Avoid Mood Altering Drugs Balance Sleep Get Exercise Build Mastery

Therapies for PTSD

Cognitive Behavioral Treatments

Exposure Treatments Other

Cognitive Behavioral Treatments

Seeking Safety Cognitive Therapy Assertiveness Training Biofeedback and Relaxation

Training Behavioral Activation

Exposure Treatments

Prolonged Exposure Cognitive Processing therapy Image Rescripting and Reprocessing Self Defense Personal safety: Safe

without Sight & Taking Charge EMDR Systematic desensitization

Other

Marital and Family Therapies Group Therapy Psychoeducation/skills training

Pharmacotherapy for PTSD

SSRIs Adrenergic blocking agents: Prazosin Other antidepressants Mood stabilizers Anti-anxiety medications

Caution in using benzodiazepines

Points to Remember:

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”