POST TRAUMATIC STRESS DISORDER

1. POST TRAUMATIC STRESS DISORDER By Moira Mardero, Elsie Yip, Curtis Richardson & Marc Baureiss

2. "Post Traumatic Stress Disorder helps us make resolution with the past. We must ride with it, not run from it. Post Traumatic Stress Disorder is not only a mental experience, but it is a spiritual and karmic experience, as well. Once you address the trauma clearly, own it and recognize it, you can release the impact of what occurred and what is not serving you. The past has no business in the present. The memories are painful, but they can't hurt you.” Coral AnikaTheill, BONSHEA: Making Light of the Dark

3. Myth or Fact? • It happened a long time ago, time heals all wounds, you should be over it. • The impacts of traumatic events are often delayed because people will banish the memories from their consciousness. • Medication is an option for people in healing from the impacts of trauma. • You will never really be normal again. • The single hardest-hit group of trauma victims is children.

4. Introduction &The History of PTSD • An emotional illness classified as an anxiety disorder • Usually the result of terribly frightening, life threatening, or otherwise highly unsafe experience • PTSD sufferers re-experience the traumatic event in some way, tend to avoid places, people that remind them of the event • Are also exquisitely sensitive to normal life experiences (hyper arousal)

5. History con’t • Condition has been around since people first experienced trauma • PTSD recognized as a formal diagnosis in 1980 • Called “soldier heart” in the American civil war • Called “combat fatigue” in WWI • Called “gross stress reaction” in WWII • Called “post-Vietnam syndrome” during Vietnam war • Also has been called “battle fatigue & shell shock”

6. Some Statistics • 7-8% of all people in the US will develop PTSD in their lifetime • 10-30% of all combat veterans and rape victims will develop PTSD • Somewhat higher in African Americans, Hispanics and Native Americans due to: • A tendency to blame themselves, have less social support, an increased perception of racism for these ethnic groups and differences in how they may express distress

7. Statistics con’t • 5 million people suffer from PTSD in the US • Women are twice as likely as men to develop PTSD • Half of the individuals who use outpatient mental health services have been found to suffer from PTSD • Not being present at a traumatic event does not guarantee that one cannot suffer from traumatic stress leading to PTSD. Ex. 2001 terrorist attacks

8. Statistics con’t • 5 million people suffer from PTSD in the US • Women are twice as likely as men to develop PTSD • Half of the individuals who use outpatient mental health services have been found to suffer from PTSD • Not being present at a traumatic event does not guarantee that one cannot suffer from traumatic stress leading to PTSD. Ex. 2001 terrorist attacks

9. Rates of PTSD in Children • Research done at Duke University: • 68% of children had direct or indirect exposure to a traumatic event by the age of 16 • Witnessing a traumatic event (23%) • Learning about a traumatic event (21.4%) • Violent death of a sibling or peer (14.5%) • Being involved in a serious accident (?)

10. Rates of PTSD in children • Being exposed to a natural disaster (11.1%) • Being diagnosed with a physical illness (11%) • Experience of sexual abuse (10.9%) • 30% of children experienced only one traumatic event while 37% had experienced multiple event • Of this study group, only 0.5% of children had a diagnosis of PTSD

11. Risk for PTSD Symptoms • Factors that increase the likelihood that a child develops PTSD after a traumatic event: • Age (being older) • Having another anxiety disorder • Multiple traumatic experiences

12. Other Negative Consequences of Childhood Trauma • These children had twice the number of other psychiatric disorders including: • Depression • Generalized anxiety disorder • Social anxiety disorder

13. PTSD DSM-IV Diagnosis & Criteria • A. The person has been exposed to a traumatic event in which both of the following have been present: • (1) An extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury • A threat to one’s physical integrity • Witnessing an event that involves death, injury or a threat to the physical integrity of another person • Learning about unexpected or violent death, serious harm by a family member or close associate

14. PTSD DSM-IV con’t • (2) The person’s response to the event must involve intense fear, helplessness, or horror • B. The traumatic event is persistently re experienced in one (or more) of the following ways: • (1) Recurrent and distressing recollections of the event (In young children, repetitive play may occur with themes or aspects of the trauma are expressed) • (2) Recurrent distressing dreams of the event

15. PTSD DSMV IV con’t • (3) Acting or feeling as if the traumatic event were recurring (a sense of reliving the experience, illusions, hallucinations, flashbacks.) • (4) Intense psychological distress at exposure to internal or external cues that symbolize an aspect of the event • (5) Physiological reactivity on exposure to cues from the event

16. PTSD DSMV IV con’t • C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by three or more of the following: • (1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma • (2) Effort to avoid activities, places or people that arouse recollections of the event • (3) Inability to recall an important aspect of the trauma

17. PTSD DSMV IV con’t • (4) Markedly diminished interest or participation in significant activities • (5) Feeling of detachment or estrangement from others • (6) Restricted range of affect (e.g. unable to have love feelings • (7) Sense of foreshortened future (e.g., does not expect to have a career, marriage, children or normal life span)

18. PTSD DSMV IV con’t • D. Persistent symptoms of increased arousal as indicated by two (or more) of the following: • (1) Difficulty falling asleep • (2) Irritability or outbursts of anger • (3) Difficulty concentrating • (4) Hyper vigilance • (5) Exaggerated startle response

19. PTSD DSMV IV con’t • E. Duration of the disturbance (symptoms in Criteria B, C and D) is more than one month • F. The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning • Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if more than 3 months • Specify if: With Delayed Onset: if at least 6 months after the stressor

20. PTSD in Infants & Toddlers (Birth to Age 1) Because infants and toddlers have difficulty communicating trauma they have experienced, the following signs of distress may be exhibited: • fussing more • possible “loss” of developmental steps already acquired • possible failure to learn new and expected developmental tasks

21. PTSD in Preschoolers (Ages 2-5) For preschoolers, whose language skills are weak and there is a limited ability to verbalize their feelings of distress, the following behaviours can be exhibited: • anxiousness and clinging to the parent/caregiver; separation difficulties • taking a step backward in development by thumb sucking, bed wetting, refusing to sleep or waking at night for fear of the dark • being aggressive in their play • speech difficulties • expressing magical ideas about an event (e.g. “ Daddy left because I was bad.”) • decreases or increases in appetite

22. PTSD in Childhood (Ages 6-12) It would be important to watch for the following signs of distress: • sadness and crying • poor concentration • fear of personal harm • bed wetting • confusion • physical complaints (e.g. headaches) • regressive behaviours (e.g. clinging, whining)

23. PTSD in Childhood con’t(Ages 6-12) • aggressive behaviour at home or school • withdrawal/social isolation • attention-seeking behaviour • school avoidance • irritability • sleep disturbances (e.g. nightmares) • anxiety and fears • eating difficulty

24. PTSD in Teenagers(Ages 13-18) • rebelliousness • intrusive recollections • anxiety and feelings of guilt • sleep and eating disturbances • antisocial behaviour (e.g. stealing) • poor school performance • increased substance abuse

25. PTSD in Teenagers con’t(Ages 13-18) • poor concentration and distractibility • psychosomatic symptoms (e.g. headaches, bowel problems) • agitation or decrease in energy level (e.g. loss of interest in activities) • numbing • aggressive behaviour • depression • peer problems • Withdrawal

26. PTSD in Adults (Ages 19 +) • shock and disbelief • feelings of detachment • unwanted, intrusive recollections • concentration difficulty • psychosomatic complaints • eating disturbance • poor work performance • emotional and mental fatigue • irritability and low frustration tolerance

27. PTSD in Adults con’t(Ages 19 +) • loss of interest in activities once enjoyed • denial • depression • anxiety • hyper-vigilance • withdrawal • sleep difficulty • emotional change • marital discord

28. Appropriate Reactions to crisis situations Shock Denial Dissociative behaviour Confusion Disorganization Difficulty making decisions Suggestibility It is crucial to give back a sense of control and to help empower the individual (Adapted from Crisis Response in Our Schools, 2003 Lerner, Volpe, Lindell)

29. The Effect of Trauma • The effects of being traumatized are very individual, and survivors are impacted physically, emotionally, behaviourally, cognitively and spiritually.

30. Physical • Eating disturbances (more or less than usual) • Sleep disturbances (more or less than usual) • Pain in areas on the body that may have been involved in the traumatic experience • Low energy • Chronic unexplained pain • Headaches • Anxiety/panic

31. Emotional • Depression, spontaneous crying, despair and hopelessness • Anxiety • Extreme vulnerability • Panic attacks • Fearfulness • Compulsive and obsessive behaviours

32. Emotional con’t • Feeling out of control • Irritability, anger and resentment • Emotional numbness • Frightening thoughts • Difficulties in relationships

33. Behavioural • Self-harm such as cutting • Substance abuse • Alcohol abuse • Gambling • Self-destructive behaviours • Isolation • Choosing friends that may be unhealthy • Suicide attempts

34. Cognitive • Memory lapses, especially about the trauma • Loss of time • Being flooded and overwhelmed with recollections of the trauma • Difficulty making decisions • Decreased ability to concentrate • Feeling distracted • Withdrawal from normal routine • Thoughts of suicide

35. Spiritual • Guilt • Shame and self-blame • Self-hatred • Feeling damaged • Feeling like a “bad” person • Questioning the presence of God

36. Spiritual con’t • Questioning one’s purpose • Thoughts of being evil, especially when abuse is perpetuated by Clergy • Turning away from the faith or obsessively attending services and praying • Feeling that as well as the individual, the whole race or culture is bad

37. PTSD and its Effect on the Brain http://www.chordsforchange.org/2010/02/04/brainonmusic/

38. Factors Shown to Increase the Likelihood of PTSD in Children • The severity of the event • Parental reaction to the event • The child’s physical and /or emotional proximity to the event

39. Helping the Child Survive the Traumatic event • Demaree (1995) states, “maintaining a safe classroom environment is the cornerstone for meeting the needs of children with PTSD” ( p. 33). Teachers can individualize their programs when they know and understand the differences and special needs of children with PTSD. This can be established by: • setting clear, consistent limits

40. Helping the Child Survive the Traumatic event • providing a positive learning environment with consistent daily routines and expectations • reassuring their safety needs by showing empathy and care • model good stress management and problem-solving skills • providing opportunities for personal control • finding positive outlets for their release of frustration and regulation of their own stress level (i.e. relaxation techniques such as yoga, singing, artwork or physical movement)

41. Helping the Child Survive the Traumatic event • reinforce the belief that conditions can and will improve despite temporary setbacks • maintaining a relationship with the child • being positive and patient with the child • incorporating more physical activity in the classroom • providing ample opportunities for students to interact with one another

42. Associated Conditions • Along with associated symptoms, there are a number of co-occurring psychiatric disorders that are commonly found in children and adolescents who have been traumatized. They include: • major depression • substance abuse • anxiety disorders such as separation anxiety, panic disorder and generalized anxiety disorder • attention-deficit/hyperactivity disorder • oppositional defiant disorder • conduct disorder

43. Associated Conditions con’t • By co-occurring, we mean: one or more Mental Health Disorders as well as one or more disorders relating to substance and/or alcohol abuse • It is estimated that 4 million people in the United States have a co-occurring disorders. • Co-occurring disorders are common with trauma survivors. They should be expected rather than seen as the exception.

44. Associated Conditions con’t • PTSD is a risk factor for substance abuse, dependence, and addiction. • The trauma survivor is often looking for a way to numb feelings, emotions, pain and suffering in an attempt to cope. • Although not mentioned in the DSM IV, disruptive behaviour disorders often co-occur in children with PTSD. • 25% ADHD • 15.4% Conduct Disorder • 25% Oppositional Defiant Disorder (Nickerson et al, 2009)

45. Resilience A set of beliefs, feelings and behaviours that emerge at a time of crisis and adversity. • Protective Factors present in resilient children • Persistence • Goal-orientation • Adaptability • Optimism • Willingness to approach novel events • High Self-esteem • Intelligence • Good social skills (Adapted from PTSD in Childhood, 2010, Chapman, Stefanation and Sukhan, Winnipeg)

46. Resiliency, What can we do? • Refer to the individual as a trauma survivor not as a victim. This reduces the sense of powerlessness. • Validate the individuals resilience and protective factors. • Build new skills and better adaptations as past coping behaviours may no longer be needed and/or acceptable. • Work from a resilience-minded perspective. • Help the trauma survivor to realizes/he has the skills from within to heal and recover.

47. The Support System School Classroom Teachers Preschool and Elementary School Age Children Adolescents Adult Students School Guidance Counselor School Psychologist Therapies provided by outside agencies

48. General role of the support system • Provide for safety and security • Help the child regain control over parts of his/her life. • Listen • Don’t minimize the child’s perception of the crisis and/or traumatic event. • Allow the child to share his/her feelings at his/her own pace. • Recognize that physical ailments and illness can be linked to PTSD. • Understand co-occurring disorders. • Collaborate with everyone involved.

49. Debriefing • Is a structure for listening and talking to the trauma survivor. • It is a way for adults to provide an environment in which children can safely express their emotions and reactions • It is not counseling

50. Goal of Debriefing • normalize the child’s responses • aid in the recovery process • allow a venue for venting • teach coping skills • help the child to understand what occurred