Post-Traumatic Stress Disorder (PTSD) Diagnosis and Implications for Treatment and Rehabilitation

1. Post-Traumatic Stress Disorder (PTSD)Diagnosis and Implications for Treatment and Rehabilitation Wendy S. David, Ph.D.AER International Conference Psychosocial Division July, 2012

2. Overview of Presentation • Trauma and PTSD • Sexual Assault • Violence and Abuse Against People with Disabilities • Treatment Interventions

3. What is PTSD? • Anxiety disorder • Terrifying Traumatic Event • Grave Physical Harm/Threat

4. Examples of Traumatic Events • Interpersonal violence • Violent criminal acts • Disasters (natural, manmade) • Accidents • Military combat • Witnessing of death and handling of body parts

5. 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

6. 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)

7. Associated Features • Disruption of Core Values and Beliefs • Pervasive distrust • Damaged self concept • Dissociation

8. 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

9. 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)

10. 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 %)

11. 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 %)

12. Risk Factors for Developing PTSD • Individual: • Previous traumatization • Prior history of abuse • Age • Gender • IQ • Personal or family history of psychiatric problems

13. Risk Factors for Developing PTSD (Cont) • Event : • Interpersonal violence (especially rape) • Chronicity of situation • Threat of death • Peritraumatic dissociation • Physical, mental, sensory disability

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

26. 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

27. Stages of Treatment & Recovery 1.Safety and Stabilization 2. Remembrance and Mourning 3. Reconnection and Integration

28. 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

29. Maladaptive vs Adaptive Coping Strategies Maladaptive Coping Adaptive Coping Strategies Use of arousal reduction techniques Limit exposure to media coverage Schedule pleasant activities Attend to physical needs Reconnect with spirituality • Drugs, Alcohol to self-medicate • Isolation from friends/supports • Stopping formerly pleasant activities • Using anger to distance or control • Workaholic as distraction

30. 2. Remembrance and Mourning Trauma 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

31. 3. Reconnection and Integration • Establishing and Living a Meaningful Life • Work • School • Family • Spirituality • Finding purpose

32. Reconnection and Integration (cont.) • Relapse Prevention • Treat Physical Illness • Balance Eating • Avoid Mood Altering Drugs • Balance Sleep • Get Exercise • Build Mastery

33. Therapies for PTSD • Cognitive Behavioral Treatments • Exposure Treatments • Other

34. Cognitive Behavioral Treatments • Seeking Safety • Cognitive Therapy • Assertiveness Training • Biofeedback and Relaxation Training • Behavioral Activation

35. Exposure Treatments • Prolonged Exposure • Cognitive Processing therapy • Image Rescripting and Reprocessing • Self Defense Personal safety: Safe without Sight & Taking Charge • EMDR • Systematic desensitization

36. Other • Marital and Family Therapies • Group Therapy • Psychoeducation/skills training

37. Pharmacotherapy for PTSD • SSRIs • Adrenergic blocking agents: Prazosin • Other antidepressants • Mood stabilizers • Anti-anxiety medications Caution in using benzodiazepines

38. 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”