Trauma- and Stressor- Related Disorders

1. Trauma- and Stressor-Related Disorders University of Manoa Anna Weihl, Christine Keanu, Genevieve Parks, Patricia Kaleiwahea

2. Trauma- and Stressor- Related Disorders This chapter includes disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include: • Adjustment Disorders • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • Other specified Trauma- and Stressor-Related Disorder • Unspecified Trauma- and Stressor-Related Disorder • Posttraumatic Stress Disorder • Acute Stress Disorder • = we will mainly be talking about these two disorders tonight

3. Overview of the Diagnostic Category of Trauma- and Stressor-Related Disorders • Adjustment Disorders • Diagnostic Criteria A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s) B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following: • 1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. • 2. Significant impairment in social, occupational, or other important areas of functioning. C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely and exacerbation of a preexisting mental disorder D. The symptoms do not represent normal bereavement E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months

4. Overview of the Diagnostic Category of Trauma- and Stressor-Related Disorders • Diagnostic Features • Prevalence • Development and Course • Risk and Prognostic Factors • Culture-Related Diagnostic Issues • Functional Consequences of Adjustment Disorders • Differential Diagnosis • Comorbidity

5. Overview of the Diagnostic Category of Trauma- and Stressor-Related Disorders Other specified Trauma- and Stressor-Related Disorder (page 289) • Symptoms are characteristic of a trauma- and stressor-related disorder, but do not meet the full criteria for any of the trauma- and stressor-related disorders diagnostic class. • This diagnose used in situations in which the clinician chooses to record “other specified trauma- and stressor-related disorder” followed by specific reason. (e.g., persistent complex bereavement disorder.) Unspecified Trauma- and Stressor-Related Disorder (page 290) • Same as above except clinician chooses not to specify the reason the criteria are not met due to insufficient information to make specific diagnose. (e.g., in emergency room settings.) Anna

6. Overview of the Diagnostic Category of Trauma- and Stressor-Related Disorders Reactive Attachment Disorder (page 265) Reactive Attachment Disorder (RAD) 313.89 • Characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance. • The essential feature is absent or grossly underdeveloped attachment between child and putative caregiving adults. • Children with RAD are believed to have the capacity to form selective attachments. However, because of limited opportunities during early development, they fail to show the behavioral manifestations of selective attachments (i.e. when distressed they show no consistent effort to obtain comfort, support, nurturance, or protection from caregivers and they do not respond more than minimally to comforting efforts of caregivers). • RAD is associated with the absence of expected comfort seeking and response to comforting behaviors. • Child with RAD emotion regulation capacity is compromised, and they display episodes of negative emotions of fear, sadness, or irritability that are not readily explained. • A diagnosis of RAD should not be made in children who are developmentally unable to form selective attachments. Thus the child must have a developmental age of at least 9 months.

7. Overview of the Diagnostic Category of Trauma- and Stressor-Related Disorders Reactive Attachment Disorder Continued(page 265) • The prevalence of RAD is unknown but relatively rarely seen in clinical settings. RAD is often found in young children exposed to severe neglect before being placed in foster care. However, even in this population the disorder is uncommon and occurs in less than 10% of those children. • There is no standard treatment for RAD, however it often includes: Individual counseling, education of parents and caregivers about the condition, parenting skills classes, family therapy, medication for other conditions that may be present (such as depression, anxiety, etc.), special education services, and residential or inpatient treatment for children with more-serious problems or who put themselves or others at risk of harm. • There are some controversial treatment practices that should be noted as they can be psychologically and physically damaging and have led to accidental deaths. These practices include: re-parenting/re-birthing/holding therapy, tightly wrapping, binding or holding children, withholding food or water, forcing child to eat or drink, and yelling, tickling or pulling limbs, triggering anger that finally leads to submission. • Here’s a video clip on holding therapy: http://www.youtube.com/watch?v=OdWhcyz6KbY

8. Overview of the Diagnostic Category of Trauma- and Stressor-Related Disorders • Disinhibited Social Engagement Disorder • Diagnostic Criteria • A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: • 1. Reduced or absent reticence in approaching and interacting with unfamiliar adults • 2. Overly familiar verbal or physical behavior • 3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings • 4. Willingness to go off with an unfamiliar adult with minimal or no hesitation • B. The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior • C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

9. Overview of the Diagnostic Category of Trauma- and Stressor-Related Disorders • 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults • 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments • 3. Rearing in unusual settings that severely limit opportunities to form selective attachments • D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A • E. The child has a developmental age of at least 9 months • Specify • Persistent- the disorder has been present for more than 12 months • Current severity – Disinhibited social engagement disorder is specified as severe when the child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels

10. Overview of the Diagnostic Category of Trauma- and Stressor-Related Disorders • Diagnostic Features • Associated Features Supporting Diagnosis • Prevalence • Development and Course • Risk and Prognostic Factors • Functional • Differential Diagnosis • Comorbidity

11. Descriptions for Acute Stress Disorder Diagnostic Criteria: A.) Client must have been exposed to actual threatened death, serious injury, or sexual violation 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 event(s) occurred to a close family member or close friend. 4.) experiencing repeated or extreme exposure to aversive details of the traumatic event(s). B.) Also, there must be the 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. (there are 14 symptoms listed in the nine categories) Specifiers: None listed Coding and recording procedures: None listed

12. Descriptions for Acute Stress Disorder, continued…. Diagnostic Features: • development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events, (traumatic event examples are listed, some stressful events do not possess the severe and traumatic components, but may lead to “adjustment disorder” diagnose instead), • typically involves an anxiety response that includes some re-experiencing or reactivity of traumatic event (e.g., strong emotional, physiological, anger, or aggressive responses at traumatic reminder). • Witnessing or learning of traumatic events are limited to close relatives or close friends, which must have been violent or accidental (listed is some examples of witnessed/learning events) • Traumatic event being re-experienced, intrusive memories (various ways listed) • Distressing dreams • Flashbacks • Psychological distress or physiological reactivity

13. Descriptions for Acute Stress Disorder, continued…. Diagnostic Features continued… • Depersonalization, de-realization (detached sense of oneself, in a daze) • Avoidance of trauma stimuli (refuse to discuss trauma, excessive alcohol use at mention of trauma, avoiding interacting if reminds of trauma) • Sleep onset and maintenance (nightmares) • Quick temper with little provocation, irritability • Concentration difficulties, memory difficulties, staying focused difficulties • Jumpiness, heightened startle response • Panic attacks, chaotic or impulsive behavior (children may display separation anxiety) Associated Features Supporting Diagnosis: • Catastrophic or extremely negative thoughts about heir role in traumatic event, or to the event itself or future likelihood of harm • Acute grief reactions or post-concussive symptoms

14. Descriptions for Acute Stress Disorder, continued…. Prevalence: • Varies according to the nature of the event and the context in which it is assessed. Development and course: • Cannot be diagnosed until 3 days after a traumatic event • May or may not progress to PTSD after 1 month (half who develop PTSD initially presented Acute Stress Disorder) • Symptoms can worsen during the initial month • Re-experiencing can vary across development, (children can report differently than adults) Functional Consequences: • Impaired functioning in social, interpersonal or occupational, also sleep, energy levels and capacity to attend to tasks. • Avoidance, withdraw, and nonattendance.

15. Descriptions for Acute Stress Disorder, continued…. Risk and Prognostic Factors: Temperamental- having prior mental health, higher levels of negativity affectivity, greater perceived severity of traumatic event(s), avoidance coping style, and/or having catastrophic appraisals of the traumatic event are strong predictors of acute stress disorder. Environmental- if been exposed to traumatic event(s), and/or has an history of prior trauma(s), greater chances of developing acute stress disorder. Genetic and Physiological- Females are at greater risk, and/or elevated reactivity before trauma(s) is another predictor of an increased risk of developing acute stress disorder after a trauma. Culture-Related Diagnostic Issues: Varies cross-culturally, particularly with respect to dissociative symptoms, nightmares, avoidance, and somatic symptoms.

16. Gender-Related Diagnostic Issues: More prevalent in females than males, maybe due to sex-linked neurobiological differences in stress response, or the likelihood of possibility of exposure to high conditional risk trauma(s) (e.g., rape, other interpersonal violence) Differential Diagnosis: Adjustment disorders: diagnose given when criteria doesn’t meet acute stress disorder’s Diagnostic Criteria A.) Panic disorder: although common in acute disorder, panic disorder is diagnosed only if panic attacks are unexpected, there is anxiety about future attacks, or there are maladaptive changes in behavior associated with fear of dire consequences of the attacks. Dissociative disorder: in absence of characteristics of acute stress disorder, severe dissociative responses can be diagnosed as de-realization/depersonalization disorder, or if severe amnesia, dissociative amnesia may be indicated. Posttraumatic stress disorder: if symptoms persist more than 1 month and meet criteria for PTSD, (acute stress must occur 1 month after trauma, and resolve with-in that 1 month period), criteria is then changed from acute stress to PTSD.

17. Differential Diagnosis continued…. Obsessive-compulsive disorder: recurrent intrusive thoughts, but not related to an experienced traumatic event, compulsions are usually present, and other symptoms of acute stress disorder are typically present. Psychotic disorder: flashbacks must be distinguished from illusions, hallucinations, or other perceptual disturbances, which may occur in schizophrenia, other psychotic disorders, depressive or bipolar disorder w/ psychotic features, a delirium, substance/medication-induced disorders, and psychotic disorders due to another medical condition. Flash are distinguished by being directly related to traumatic experience and by occurring in the absence of other psychotic or substance-induced features. Traumatic brain injury (TBI): symptoms for a brain injury from traumatic event(s), and symptoms previously termed post-concussive can overlap with symptoms of acute stress disorder, however re-experiencing and avoidance are characteristics of acute stress disorder where as persistent disorientation and confusion are more specific to TBI. Also, symptoms of acute stress disorder persist for up to only 1 month following trauma exposure.

18. Acute Stress Disorder/YouTube Video http://www.youtube.com/watch?v=Al1A0t1vWzk (1 minute, 55 seconds)

19. EBP for Acute Stress Disorder?? Imagery rehearsal Prolonged exposure techniques Case management Group therapies including present-centered and trauma-focused group therapies Optimism training Goal setting and achievement Biofeedback Multiple channel exposure therapy Assertiveness training Outward Bound group recreational therapies http://www.nrepp.samhsa.gov/ Psychotherapeutic Interventions: • Cognitive behavior therapy • Patient utilization of existing support network • Psychological debriefing • Single-session therapy • Eye movement desensitization and reprocessing (EMDR) • Reactive eye dilation desensitization and reprocessing (REDDR) • Hypnotherapy • Desensitization • Relaxation exercises • Internet based therapies • Stress inoculation

20. Eye Movement Desensitization and Reprocessing (EMDR) Eye Movement Desensitization and Reprocessing (EMDR) is said to be an effective psychotherapeutic approach for treatment of traumatic memories. It is an “empirically supported integrative psychotherapeutic approach for treatment of Post-Traumatic Stress Disorder (PTSD)” (Van der Hart, Nijenhuis, Solomon, 2010). It is not only used to treat Post-Traumatic Stress Disorder but any other disturbing event that the individual finds him-self unable to move through in a healthy way. “EMDR involves a neurobiological process that helps the individual reprocess a traumatic or disturbing event into an experience that can be remembered without pain” (Shapiro, Forrest, 2004). One of the goals and objectives in treatment is to use EMDR to resolve disturbing events (trauma), the identification and utilization of resources, and for future scripting. Basically, by processing negative cognitions through EMDR, an increased ability to self-regulate emotional responses is seen. • http://www.youtube.com/watch?v=KpRQvcW2kUM

21. 4 Literature Reviews on the EBP EMDR for ASD 1.) Kutz, et. al, 2008, found that “a single session of modified and abridged protocol of EMDR was found to provide complete relief for 50% and substantial relief for another 27% of acutely stressed patients, most of whom had been exposed to an isolated traumatic event. While the standard EMDR protocol is geared as a comprehensive approach for chronic patients with multiple accumulating issues, this single-session abridged protocol was effective for focused symptom relief in the early phases. 2.) The American Journal of Psychiatry, et. al, 2004, compared EMDR with no treatment, cognitive behavior therapy, exposure approaches (not involving in vivo exposure), variants of EMDR (e.g., dismantling studies), and “nonspecific” treatments. EMDR was more effective than no treatment and comparable to other active treatments.

22. 4 Literature Reviews on the EBP EMDR for ASD continued… 3.) An article in the Wiley Inter Science Journal, 2009, found that “symptom reduction has been shown to be comparable over treatment with EMDR …and the 6-month follow-up, EMDR had the superior outcome. In studies that had diagnosis as an outcome measure, between 77% and 90% of EMDR patients no longer met diagnostic criteria for PTSD at the end of treatment. 4.) “Researchers found that only trauma-focused CBT and EMDR produced significant clinical improvements, and no major differences were found between the two in head-to-head comparison studies” (Kennedy, et. al., 2007).

23. Posttraumatic Stress Disorder YouTube Video http://www.bing.com/videos/search?q=George+Carlin+Ptsd&Form=VQFRVP#view=detail&mid=9B6B008519D3B722036E9B6B008519D3B722036E

24. PTSD ETIOLOGY/CRITERIA PTSD is an anxiety disorder that develops in response to • Exposure to actual or threatened death, serious injury, or sexual violence by directly experiencing, witnessing the event, learning that the traumatic event happened to a close family member or friend, and experiencing repeated exposure THOSE AT-RISK INCLUDE: • People who have been in a natural disaster, such as a tidal wave, earthquake, tornado or tsunami. • Anyone who have been raped or physically or sexually abused. • Anyone who have witnessed or been a part of a life-threatening event. • Anyone with military combat experience or even civilians who have been injured in war.

25. PTSD ETIOLOGY/CRITERIA • Presence of one (or more) of the following symptoms associated with the traumatic events, beginning after the traumatic event(s) occurred: • Re-experiencing the event involuntarily through distressing memories(flashbacks) • Re-experiencing nightmares or distressing dreams in which it is related to traumatic event. • Dissociative reactions(flashbacks) where individual feels or acts as if the traumatic event was recurring. • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) • Marked physiological reactions such as Numbness, Insomnia, Lack of concentration.

26. PTSD ETIOLOGY/CRITERIA • Persistent avoidance of stimuli associated with the traumatic event(s) • Avoiding people, places, conversations, etc. that arouse distressing memories of traumatic event. • Avoiding distressing memories, thoughts, or feelings about or associated with the traumatic event. • Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred. • Marked alterations in arousal and reactivity associated with the traumatic event. • Duration of the disturbance is more than 1 month. • Disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers. • Disturbance is not attributable to the physiological effects of a substance(medication or alcohol) or another medical condition.

27. Prevalence • Projected lifetime risk of PTSD rates higher among veterans as well as police, firefighters, emergency medical personnel (jobs high risk) • Projected lifetime risk for PTSD at age 75 years is 8.7%(U.S.) • Twelve-month prevalence among U.S. adults is 3.5% • Europe and most Asian, African, and Latin American countries have lower estimates of .5%-1.0% • Highest rates are found among survivors of rape, military combat, and ethnically or politically motivated internment and genocide.

28. Development and course • Any age (beginning after the 1st year of life) • Symptoms begin approximately 3 months after traumatic event • Abundant evidence for what DSM-IV called “delayed onset” now called “delayed expression” which is a delay in meeting full criteria • ½ of adults will experience complete recovery within 3 months • Symptoms for some lasts more than 12 month and for others more than 50 years

29. Functional Consequences PTSD ASSOCIATED WITH: • High levels of social, occupational, and physical disability • Considerable economic costs • Impaired functioning across social, interpersonal, developmental, educational, physical health, and occupational domains • Poor social and family relationships, work absences, lower income, lower educational and occupational success. • High levels of medical utilization

30. Evidence Based Practices: Pharmacotherapy Post-Traumatic Stress Disorder in Women • SSRI’s (Selective serotonin reuptake inhibitor)remain a first-line pharmacotherapy for PTSD, although mood stabilizers, newer antidepressants, atypical antipsychotics and adrenergic agents have some evidence for efficacy. SSRI’s were the first class of psychotropic drugs discovered and are the most widely prescribed antidepressants in many countries. • CBT, although randomized, comparative studies do not provide evidence for superiority of one intervention over another • Exposure therapy and cognitive processing have been demonstrated to work well in women with PTSD following adult victimization or childhood abuse.

31. Evidence Based Practices: Pharmacotherapy CURRENT STATUS OF PHARMACOTHERAPY FOR PTSD: AN EFFECT SIZE ANALYSIS OF CONTROLLED STUDIES • Findings suggested that serotonergic antidepressants for the treatment of PTSD are effective and of a relative advantage • Effective medications for conditions characterized by pervasive anxiety, intrusive thoughts, and avoidance (PTSD) may have strong but extreme selectivity for blocking reuptake of serotonin over norepinephrine. • Serotonergic agents for treatment of PTSD is encouraged

32. Evidence Based Practices: CBT EMDR A Community-Based study of EMDR and Prolonged Exposure • Pilot study which compared prolonged exposure and EMDR • 22 patients from a university based clinic serving rape and crime victims • Results showed that both approaches produced significant reduction in PTSD and depression symptoms • Success was faster with EMDR with 7 of 10 of the participants having 70% reduction in PTSD symptoms as compared to PE which was 2 of 10 • EMDR better tolerated by participants thus having lower drop out rate • However patients who remained in PE had reduction of PTSD scores as well • Results of this study suggest that both PE and EMDR equally effective in reducing symptoms of PTSD and depression

33. Evidence Based Practices: CBT Prolonged Exposure Treatment choice for PTSD • Study on 273 women with varying degrees of trauma history and subsequent PTSD symptoms. • All participants were given the same sexual assault scenario and three treatment options to choose from which included: Sertraline(SER), prolonged exposure(PE), or no treatment. Question “if this happened to you, what would you do” • Treatment choice, reaction to treatment options, and treatment credibility were examined. • Women were more likely to choose PE for treatment of chronic PTSD.

34. Description for Culture: Women Overview: Forging Research Priorities for Women’s Mental Health By Nancy Felipe Russo Prevalence Rates - Frequencies and patterns of mental disorder are vastly different for women and men. - The NIMH Epidemiological Catchment Area Program found that there are substantial gender differences in prevalence rates of lifetime diagnoses: (a) women clearly predominate in diagnoses of major depressive episodes, agoraphobia, and simple phobia, whereas men predominate in antisocial personality disorder and alcohol abuse/dependence; (b) women are more likely than men to have received a diagnosis of dysthymia, obsessive-compulsive, schizophrenia, somatization disorder, and panic disorder; and (c) no gender differences in manic episode or cognitive impairment.

35. Description for Culture: Women Utilization Rates - There are marked differences between men and women in the utilization of mental health services, differences that vary with type of facility. - For inpatient facilities, women make up a greater proportion of admissions than men in nonfederal general hospitals and private mental hospitals men predominate in admission to state and county mental hospitals and Veterans Administration hospitals. - For outpatient facilities, female clients predominate. Diagnosis Related to Gender, Marital Status and Ethnicity - There are gender differences in diagnosis that vary by marital status and race/ethnicity and that cannot be explained by biomedical models. - The relationships among gender, marital status, and psychological disorder depends on the psychological disorder and vary with ethnicity.

36. Description for Culture: Women Overview: Forging Research Priorities for Women’s Mental Health By Nancy Felipe Russo Diagnosis and Service Delivery - Patterns of mental disorder vary markedly for men and women whether data from community surveys or from patient populations are used. - According to community surveys, women predominantly are diagnosed with the more severe forms of psychiatric disorders but according to service delivery research, men predominate in the more intensive community treatment settings (residential and partial care vs. outpatient). The question remains does this represent a desirable outcome of treating females in less restrictive settings or does it show that females are underserved.

37. Description for Culture: Women Overview: Forging Research Priorities for Women’s Mental Health By Nancy Felipe Russo Multiple Roles and Women’s Mental Health - Women typically have multiple roles that they are fulfilling (mother, wife, employee, etc.) and this can affect their mental health. - Parenting is one caretaking role that affects women more than men. According to McBride (1988), parenthood, particularly when children are young, increases the symptoms of psychological distress for women whether or not they work outside the home and the symptoms appear to increase with the number of children living in the home.

38. Description for Culture: Women Prevalence of Civilian Trauma and Posttramatic Stress Disorder in a Representative National Sample of Women By Resnick, H.S., et al. • The study assessed prevalence of crime and noncrime civilian traumatic events, lifetime posttraumatic stress disorder (PTSD), and PTSD in the last six months amongst a sample of 4,008 U.S. adult women. • The study found that lifetime exposure to any type of traumatic event was 69%, whereas exposure to crimes that included sexual or aggravated assault or homicide of a close relative or friend occurred among 36%. • The overall prevalence of PTSD was 12.3% lifetime and 4.6% within the past 6 months. • The rate of PTSD was significantly higher among crime versus noncrime victims (25.8% vs. 9.4%). • History of incidents that included direct threat to life or receipt of injury was a risk factor for PTSD in women.

39. Description for Culture: Women Trauma Exposure and Posttraumatic Symptoms in Hawaii: Gender, Ethnicity, and Social Context By Klest, B., Freyd, J.J., & Foynes, M.M. • This was a longitudinal cohort study of 833 members of an ethnically diverse group in Hawaii, who were surveyed about their personal exposure to several types of traumatic events, socioeconomic resources and mental health symptoms. • Findings were that men and women are exposed to similar rates of trauma overall. However, women report more exposure to traumas high in betrayal and men report exposure to more traumas lower in betrayal. • Trauma exposure was predictive of mental health symptoms. Neglect, household dysfunction, and high betrayal traumas predicted symptoms of depression, anxiety, PTSD, dissociation, and sleep disturbance. Lower in betrayal traumas predicted PTSD and dissociation symptoms. • Results suggest that more inclusive definitions of trauma are important for gender equity.

40. Description for Culture: Women “Although women are exposed to proportionately fewer traumatic events in their lifetime than men, they have a higher lifetime risk of PTSD” (Seedat, Stein, and Carey, 2005) Studies show risk factors for PTSD in women include - higher incidents of sexual assault and intimate partner violence. - peritraumatic dissociation (dissociation that occurs at the time of a trauma) is a strong predictor of PTSD - pregnancy, traumatic childbirth, pregnancy loss - neurobiological dysregulation resulting from sensitization to stress hormones (epinephrine and cortisol) - concurrent PTSD and increased alcohol use is seen significantly more in women

41. Description for Culture: Women • Resilience and Recovery • Resilience – reflects the ability to maintain stable equilibrium • Recovery – connotes a trajectory in which normal functioning temporarily gives way to symptoms of depression, PTSD, or other • Creating a therapeutic alliance – building trust • Client-centered • Validation • Non-threatening • Holistic - looking at various aspects of a woman’s life and environment • (Seedat, et.al., 2005; Olff, Draijer, Langeland, Gersons, 2007; Grieger, Fullerton, & Ursano, 2003)

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43. References (continued) Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., & Best, C. L. (1993). Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of consulting and clinical psychology, 61(6), 984. Ruglass, L. V. (2012). Helping Alliance, Retention, and Treatment Outcomes: A Secondary Analysis From the NIDA Clinical Trials Network Women and Trauma Study. Substance Use & Misuse, 47(6), 695-707. Russo, N. F. (1990). Overview: Forging research priorities for women's mental health. American Psychologist, 45(3), 368. Seedate, S.D., Stein, D.J., Carey, P.D. (2005). Post-Traumatic Stress Disorder in Women: Epidemiological and Treatment Issues. CNS Drugs. 19(5), 411-427. Shapiro, F. (2004). Emdr: The Breakthrough Eye Movement Therapy for Overcoming Anxiety, Stress, and Trauma. Basic Books. Van der Hart, O., Nijenhuis, E. R., & Solomon, R. (2010). Dissociation of the personality in complex trauma-related disorders and EMDR: Theoretical considerations. Journal of EMDR Practice and Research, 4(2), 76-92.