sorting through the signs and symptoms: understanding ... · posttraumatic stress disorder b....

Sorting through the Signs and Symptoms:

Understanding & Treating

Posttraumatic Stress Disorder

Jessica Holton, MSW, LCSW, LCAS

Holton, 2014 1

Learning Objectives

1. Participants will be able to compare the diagnostic criteria of PTSD from the DSM-IV-TR to the DSM-5.

2. Participants will understand the neurobiology of trauma.

3. Participants will apply effective treatment technique specific to PTSD.

Holton, 2014 2

Signs and Symptoms

Signs – Cues that can be witnessed by others (fidgeting, darting eye gaze, tearful, et cetera)

Symptoms – Subjective, self-reported, and typically cannot be witnessed (feeling anxious, feeling apprehensive, chronic pain)

Holton, 2014 3

Signs and Symptoms

Loss of interest

Difficulty concentrating

Irritability or anger out bursts

Sleep difficulties

Avoidance

Holton, 2014 4

Individuals Seek Treatment For:

Depression

Mood Swings

Anger

Substance Abuse

Relationship Issues

Concentration Struggles

Legal Issues

Sleep Difficulties

Chronic Pain Holton, 2014 5

Possible Disorders or Diagnoses

Attention-Deficit/Hyperactivity Disorder?

Major Depressive Disorder?

Generalized Anxiety Disorder?

Bipolar Disorder?

Schizoaffective Disorder?

Posttraumatic Stress Disorder?

Acute Stress Disorder?

Substance Induced __________?

Adjustment Disorder?

Holton, 2014 6

DSM-IV-TR


Holton, 2014 7


First and foremost:

A. The person has been exposed to a traumatic event in which BOTH of the following were present:

1. The person EXPERIENCED, WITNESSED, or WAS CONFRONTED with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

2. The person’s response involved INTENSE FEAR, HELPLESSNESS, or HORROR.

Holton, 2014 8


If BOTH criteria in section A is met,

then one can proceed with the

exploring the PTSD diagnosis further.

Holton, 2014 9


REEXPERIENCING:

B. The traumatic event is PERSISTENTLY REEXPERIENCED in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, and perceptions.

2. Recurrent distressing dreams of the event.

3. Acting or feeling as if the traumatic event were recurring.

Holton, 2014 10


REEXPERIENCING (continued):

B. The traumatic event is PERSISTENTLY REEXPERIENCED in one (or more) of the following ways:

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

Holton, 2014 11


AVOIDANCE:

C. Persistent AVOIDANCE of stimuli associated with the trauma and NUMBING of the general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma

2. Efforts to avoid activities, places, or people that arouse recollections of the trauma

3. Inability to recall an important aspect of the trauma

Holton, 2014 12


AVOIDANCE (continued):

C. Persistent AVOIDANCE of stimuli associated with the trauma and NUMBING of the general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

4. Markedly diminished interest or participation in significant activities

5. Feeling of detachment or estrangement from others

6. Restricted range of affect (emotional expression)

7. Sense of a foreshortened future

Holton, 2014 13


AROUSAL:

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating

4. Hypervigilance

5. Exaggerated startle response

Holton, 2014 14


Duration:

E. Duration of the disturbance is more that one month (less than one month could be Acute Stress Disorder)

Disturbance In Functioning:

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify:

Acute – Durations of symptoms is less than three months

Chronic – Duration of symptoms is three months or more

With Delayed Onset – Onset of symptoms is at least six months after the stressor

Holton, 2014 15

Acute Stress Disorder

First and foremost, as with PTSD:

A. The person has been exposed to a traumatic event in which BOTH of the following were present:

1. The person EXPERIENCED, WITNESSED, or WAS CONFRONTED with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

2. The person’s response involved INTENSE FEAR, HELPLESSNESS, or HORROR.

Holton, 2014 16


DISSOCIATIVE:

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

1. A subjective sense of numbing, detachment, or absence of emotional responsiveness

2. A reduction in awareness of his or her surroundings (“being in a daze”)

3. Derealization

4. Depersonalization

5. Dissociative amnesia (inability to recall an important aspects of the trauma)

Holton, 2014 17


REEXPERIENCED:

C. The traumatic event is PERSISTENTLY REEXPERIENCED in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to the reminders of the traumatic event.

AVOIDANCE:

D. Marked AVOIDANCE of stimuli that arouse recollections of the trauma (thoughts, feelings, conversations, activities, places, people, et cetera)

Holton, 2014 18


AROUSAL:

E. Marked symptoms of anxiety or INCREASED AROUSAL (difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

DISTURBANCE

F. The DISTURBANCE caused clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs individual’s ability to pursue some necessary tasks, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

Holton, 2014 19


DURATION:

G. The disturbance lasts from a MINIMUM of TWO DAYS and the MAXIMUM of FOUR WEEKS (ONE MONTH) of the traumatic event.

**If the signs and symptoms are present for one month or longer, the diagnosis transitions to PTSD

RULING OUT:

H. The disturbance is not due to the direct physiological effects of substance abuse or medication, or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II Disorder.

Holton, 2014 20

DSM-5

(effective Oct. 1, 2014)


Holton, 2014 21


• No longer listed under Anxiety Disorders.

• Separate section of Trauma- and Stressor-Related Disorders

• Reactive Attachment Disorder

• Disinhibited Social Engagement Disorder

• Posttraumatic Stress Disorder

• Acute Stress Disorder

• Adjustment Disorders

• Other Specified Trauma- and Stressor-Related Disorder (not the same as Not Otherwise Specified)

• Stressor criterion is more explicit.

• Expansion of symptom clusters.

• Criterion different for children 6 years old and younger.

Holton, 2014 22


The following criteria not applicable to children younger than 6 years old.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of traumatic event(s) (e.g., first responders; police officers repeatedly exposed to details of child abuse).

Note: Does not apply to exposure through electronic media, television, movies or pictures, unless exposure is work related.

Holton, 201 23


B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

3. Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Reactions may occur on a continuum.)

4. Intense prolonged psychological distress at the exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Holton, 201 24


C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with traumatic event(s).

Holton, 201 25


D. Negative alteration in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined.”)

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g. fear, horror, anger, guilt, or shame).

5. Markedly diminished interest or participant in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Holton, 201 26

Posttraumatic Stress Disorder E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or now provocation) typically expressed as verbal or physical aggression toward people or objects.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Holton, 201 27


F. Duration of the disturbance is more that one month (less than one month could be Acute Stress Disorder)

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Holton, 2014 28


Specify whether:

With dissociative symptoms

1. Depersonalization

2. Derealization

Specify if:

With delayed expression

Holton, 2014 29


A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of traumatic event(s) (e.g., first responders; police officers repeatedly exposed to details of child abuse).

Note: Does not apply to exposure through electronic media, television, movies or pictures, unless exposure is work related.

Holton, 201 30


B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion Symptoms

Negative Mood

Dissociative Symptoms

Avoidance Symptoms

Arousal Symptoms

Holton, 201 31


C. Duration of the disturbance is three days to one month after trauma exposure.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

Holton, 2014 32

Neurobiology of Trauma

Holton, 2014 33

Our Brain…

Holton, 2014 34

Thought and Control Center

Emotions

Survival (Flight/Fight/Freeze)

The way the brain SHOULD allocate resources for optimal development and functioning:

Holton, 2014 35

EXAMPLES OF TRAUMATIC EVENTS

COMBAT / WAR ZONE

MOTOR VEHICLE ACCIDENT

EXPERIENCING ABUSE (PHYSICAL, SEXUAL, VERBAL, EMOTIONAL)

MEDICAL TRAUMA

WITNESSING OR EXPERIENCING DOMESTIC VIOLENCE

WITNESSING DEATH

NATURAL DISASTERS

VIOLENT LIVING ENVIRONMENT

Holton, 2014 36

Thought and

Control Center

Emotions

Survival (Fight/Flight/Freeze)

The way the brain allocates resources when traumatized:

Holton, 2014 37

Holton, 2014 38

Stress and Stress Responses

Holton, 2014 39

Emotional stress can affect you physically,

emotionally, spiritually, mentally and socially.

PHYSICAL

appetite changes

headaches

tension

fatigue

insomnia

weight change

colds

muscle aches

digestive upsets

pounding heart

accident prone

teeth grinding

rashes or skin problems

restlessness

foot-tapping

finger-drumming

increased alcohol, drug or tobacco use

Holton, 2014 40

STRESS RESPONSES

MENTAL

forgetful

dull senses

poor concentration

low productivity

negative attitude

EMOTIONAL

anxiety

frustration

the “blues”

mood swings

bad temper

nightmares

crying spells

irritability

“no one cares”

depression

nervous laugh

worrying

easily discouraged

little joy

Holton, 2014 41

STRESS RESPONSES SPIRITUAL

emptiness

loss of meaning

doubt

unforgiving

martyrdom

looking for magic

loss of direction

needing to “prove” self

Cynicism

apathy

Holton, 2014 42

STRESS RESPONSES SOCIAL

isolation

intolerance

loneliness

lashing out

hiding

clamming up

lowered sex drive

nagging

distrust

fewer contacts with friends

lack of intimacy

confusion

lethargy

whirling mind

no new ideas

boredom

spacing out

negative self-talk

using people

Holton, 2014 43

Coping Skills

Holton, 2014 44

Types of Coping

Action-based coping

Action-based coping involves actually dealing with a problem that is causing stress. Examples can include getting a second job in the face of financial difficulties, or studying to prepare for exams. Examples of action-based coping include planning, suppression of competing activities, confrontation, self-control, and restraint.

Holton, 2014 45

Types of Coping

Emotion-based coping

Emotion-based coping skills reduce the symptoms of stress without addressing the source of the stress. Sleeping or discussing the stress with a friend are all emotion-based coping strategies. Other examples include denial, rationalization, repression, wishful thinking, distraction, relaxation, and humor. There are both positive and negative coping methods.

Holton, 2014 46

Unhealthy Coping Skills

Harmful coping methods

Some coping methods are more like habits than skills, and can be harmful. Overused, they may actually worsen one's condition. Alcohol, cocaine, and other drugs may provide temporary escape from one's problems, but, with excess use, ultimately result in greater problems. Other less extreme cases involve skin biting, nail biting, and hair pulling.

Holton, 2014 47

Assessment and Rapport Building

Holton, 2014 48

Holton, 2014

49

PERSON-IN-ENVIORNMENT (PIE) APPROACH

It is essential to get the whole picturewhole picture, first handfirst hand, and consider various perceptions.

Individuals grow and change, thus understand that they are often at a different leveldifferent level (either better or worse) as their experiences change.

If coco--occurring diagnosis are presentoccurring diagnosis are present, realize that the conditions need to be addressed at the same timesame time!

Holton, 2014 50

UNDERLYING ISSUES & ADDICTION

Are their links between the addictionaddiction and mood symptoms?mood symptoms? Which occurred first?

Are there patterns of unhealthy behaviors, such as anger outburstsanger outbursts, turbulent turbulent relationships (codependency), minimizing relationships (codependency), minimizing issues (denial), control issues (external issues (denial), control issues (external locus of control), low selflocus of control), low self--esteemesteem, low selflow self--worth, etc?worth, etc?

It is necessary to understand It is necessary to understand

feelings and emotions.feelings and emotions. Holton, 2014 51

What triggers unhealthy coping skills?

How to cope with the triggers and cravings in a healthyhealthy way?

Methods to rere--traintrain the middle brain. It takes tools, time and practice to re-train that “survival centersurvival center” of the brain.

Establish and practice positivepositive, supportivesupportive and safesafe interactions to encourage replacing the dysfunctional behaviors to functional behaviors.

LivingLiving compared to SurvivingSurviving

Being a WitnessWitness rather than a VictimVictim! Holton, 2014 52

Georgi, J. M., 2004

Treatment Considerations

Holton, 2014 53

Scope of Practice

Clinicians who specialize in treating trauma

Clinicians who understand, and are able to work with, individuals with legal issues

Clinician who specialize in treating co-occurring disorders

PTSD and Substance Use

PTSD and Chronic Pain

PTSD, Generalized Anxiety Disorder, and Substance Use

Holton, 2014 54

TREATMENT MODALITIES

CBT- Cognitive Behavioral Therapy

TF-CBT – Trauma Focused – Cognitive Behavioral Therapy

Biofeedback & Neurofeedback

DBT – Dialectal Behavioral Therapy

CPT – Cognitive Processing Therapy

EMDR - Eye Movement Desensitization and Reprocessing

Holton, 2014 55

Trauma Focused – Cognitive Behavioral Therapy (TF-CBT)

Emotional Identification

Stress Management

Coping Skills

Though Distortions

Psychoeducation

Narrative or Letters

Safety and/or Boundaries

Evaluation Holton, 2014 56

Trauma Focused – Cognitive Behavioral Therapy

COGNITIVE TRIANGLE

HOW IT’S ALL RELATED . . .

Something Happens

Thoughts

Feelings Behaviors

Holton, 2014 57

Suggested Models, Methods, & Techniques

Holton, 2014 58

Daily Gratitude Journal

• Successes / Positives

• Challenges / Negatives

• What are you grateful for?

Holton, 2014 59

Deep Breathing

Breathe in and out from your diaphragm (not chest).

Breathe in for four (4) seconds

Breathe out for four(4) seconds

This is one (1) cycle

Complete at least six (6) to twelve (12) cycles

This changes the blood flow from your chest

(heart and lungs = preparing for Survival - Fight and Flight)

to your extremities (arms and hands), which cues the brain that it is no longer in Survival - Fight or Flight - mode.

Holton, 2014 60

Activities that Engage Frontal Lobe

(Re-allocate energy from the Limbic System, to Frontal Lobe)

Counting

Adding

Subtracting

Organizing

Alphabetizing

Word Searches

Jigsaw Puzzles

Balancing on one leg

Hopping on one leg

*Mindfulness

*Grounding

This type of action based coping pulls energy to the frontal lobe (thought and control center) and away from the Limbic System (intricate Fight and

Flight/Survival Center). Holton, 2014 61

Biofeedback Mantra

“My mind is quite quiet. My hands are warm and heavy.”

Repeat the above mantra while visualizing your hands glowing bright. Feel your hands warming up and being weighted down.

This changes the blood flow from your chest (heart and lungs = Fight and Flight/Survival) to your extremities (arms and hands), which cues the brain that it is no longer in Fight or Flight/Survival.

Can be used as preventative or action based coping. Data has indicated that this exercise assists in preventing:

Migraines

High Blood Pressure

Anxiety

Headaches

TMJ Holton, 2014 62

Anxiety Management Mantras

“Fear is not real. Danger is real.”

“Anxiety is my fear, linked to the future, linked to my imagination.”

“What are the facts that counter is fear/anxiety?”

“Focusing on anxious thoughts is similar to wishing for the very thing that I fear.”

F.E.A.R. = Forget Everything and Run;

False Evidence Appearing Real

OR

Face Everything and Recover Holton, 2014 63

Danger Sequence

Am I in danger? Fear is not real. Danger is. 95-99% of the time, I am not in danger.

• The answer is NO

Are past traumas (real saber tooth tigers) being triggered?

• If yes, counter with facts: Age, location, year, individuals involved, actions, ect.

• If no, move to #3.

Are past negative life (mutated saber tooth tigers) events being triggered?

• If yes, counter with facts: Age, location, year, individuals involved, actions, ect.

• If no, move to #4

What are the specific stressors (hologram saber tooth tigers)?

What are the tangible solutions (not anxiety or fear based)

Follow sequence, without adaptions. Repeat often. Practice on small stressors in order to build “muscle memory” for the larger stressors, trauma triggers, and/or crisis that might occur.

Holton, 2014 64

Grieving Process:

1) Shock/Denial

2) Anger

3) Bargaining

4) Depression

5) Acceptance Marrone, 1997

Holton, 2014 65

Holton, 2014 66

Holton, 2014 67

Revised Healing Process:

1) Denial

2) Bargaining

3) Anger (Projection)

4) Depression (Blah, Guilt)

5) Acceptance (Sobriety)

Holton, 2014 68

“Stages of Change” “Stages of Change” -- It’s A It’s A ProcessProcess

Precontemplation (Denial): Not thinking of quitting Feel that things are fine Do not see a problem

Contemplation(Bargaining): Thinking of quitting Thinking of how others have been affected Try small changes

Preparation (Bargaining & Anger): Have a plan to quit May have “cut down” on use Can see the positives of being clean

Action(Anger & Depression): Have quit using Avoiding triggers Ask others for help

Maintenance (Acceptance): Have not used in a long time Accept self and sobriety Help others who still use

Velasquez, Maurer, Crouch, & DiClemente.,2001

Holton, 2014 69

Smartphone Apps

• PTSD Coach

• Breath2Relax

• T2 Mood Tracker

Holton, 2014 70

SUCCESS

To laugh often and much; to win the respect of

intelligent people and the affection of children; to earn

the appreciation of honest critics and endure the

betrayal of false friends; to appreciate beauty; to find the

best in others; to leave the world a bit better, whether by

a healthy child, a garden patch, or a redeemed social

condition; to know even one life has breathed easier

because you lived; this is to have succeeded.

--attributed to Ralph Waldo Emerson

(1803-1882)

Holton, 2014 71

THOUGHTS, COMMENTS

OR QUESTIONS?

Holton, 2014 72

For more information, contact:

Jessica Holton

MSW, LCSW, LCAS

Jessica Holton, PLLC

http://www.jessicaholton.com

3491 Evans Street

Suite A

Greenville, NC 27834

252-987-3039 [email protected]

Holton, 2014 73

References American Psychiatric Association (2013). Diagnostic and statistical manual

of mental disorders (5th ed.). : Author. Arlington, VA: Author.

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author.

Georgi, J. M. (2004). Treatment issues for dual diagnosis: Post traumatic stress disorder and substance abuse. Presentation sponsored by Eastern AHEC. Greenville, NC.

Saeed, S. (2013). From DSM-IV-TR to DSM—5: What specifically is changing? Presentation sponsored by Eastern AHEC. Greenville, NC.

Sidbury, L. & Owens, C. (2005). Critical incident stress and emergency response. Presentation sponsored by Pitt Community College. Greenville, NC.

Valasquez, M.M., Gaylyn, G.M., Crouch, C. & DiClemente, C.C. (2001). Group treatment for substance abuse: A stages-of-change therapy manual. New York: The Guilford Press.

Holton, 2014 74

sorting through the signs and symptoms: understanding ... · posttraumatic stress disorder b....

Documents