Case Study

1. Case Study 7th grade boy presents for treatment. Client has been referred due to oppositional behaviors, ditching school, fighting, and failing grades.

2. Post Traumatic Stress Disorder

3. Post Traumatic Stress Disorder Ethos � How trustworthy is the presenter (you) and does your audience like you? Pathos � What are the values of the audience and what motivates them? Logos � How reasonable, straightforward, and well-documented is your argument? Ethos � How trustworthy is the presenter (you) and does your audience like you? Pathos � What are the values of the audience and what motivates them? Logos � How reasonable, straightforward, and well-documented is your argument?

4. Potentially Traumatic Events War Terrorism Physical Assault Sexual Assault Being teased? Embarrassing Moments Natural Disaster Death of loved one Domestic Violence Child Abuse Witness of events Emotional Abuse

5. PTSD Stats Est 5.2 million Americans dx between 18-54yrs old (3.6%). 1 million Vietnam Vets affected. What about Iraq and Afghanistan ? 2x number of women affected vs men. Often co-exist with depression, alcohol or other substance, or other anxiety disorders.

6. Maslow

7. Basic Anatomy Our brain develops from back to front: primitive - executive functions arise in that order.

8. Lymbic System The oldest part of the brain: This system is most responsible for our flight or fight system. It includes structures involved in emotion, motivation and emotional association with memory.

9. Corpus Callosum Each hemisphere of the human brain is a conscious system in its own right, perceiving, thinking, remembering,reasoning, willing and emoting. If the two hemispheres are separated, each is able to produce its own consciousness.

10. Thalamus Major relay station that monitors and processes incoming info before it�s sent to the upper regions of the brain. Receives auditory, somatosensory and visual sensory signals

11. Hypothalamus Regulates the autonomic nervous system via hormone production and release. Initiates feelings, actions and emotions such as hunger, thirst, rage & terror. Affects and regulates blood pressure, sexual arousal and the sleep/wake cycle.

12. Hippocampus Involved with recognizing new experiences and with learning and memory, especially short-term memory and information relating to recent events.

13. Amygdala Stores emotional parts of memory, especially powerful feelings; also concerned with emotions such as anger and jealousy, and drives such as hunger, thirst and sexual desire.

14. Importance of the fear center

15. Memory

16. Memory

17. Types of Memory Most memories are based on sensory imput such as smell, sight and sound. Iconic Memory Echoic Memory Short Term Memory Long Term Memory Semantic Memory (facts: events) Episodic Memory (episodes: self across time)

18. Iconic Memory Held for less than a second Based on sight Allows us to perceive lots of visual info, but not recall it. i.e. subliminal messages at movie theatres

19. Echoic Memory Used for hearing Lasts longer than iconic (approx 4 sec) Allows us to remember last few items read out loud from a list. Allows us to figure out direction of sound Done by calculating difference between time when a sound is registered in one ear vs the other.

20. Short Term Memory Also known as working memory Used to manipulate info (mental mapping for directions) Used to store small amounts for short periods (30-45 sec) Quickly disappears by default - unless needed

21. Long Term Memory Structure: Hippocampus Anything from one minute - lifetime Needs to be encoded (associated in a meaningful way) Associated in a meaningful way Consolidated and stored (permanent neuron change) Believed to occur during dreaming (REM sleep)

22. Long Term Memory Implicit Knowledge Actions or procedures Driving, dancing� Explicit Knowledge Facts and scenes from our past

23. Hebb�s Axiom From the beginning of life, the brain responds to experience with the establishment of connections among neurons. Those pathways activated simultaneously become associated with one another and are more likely to be activated together again in the future.

24. Forgetting Interference Theory Info is not lost, rather hidden from conscious Retroactive Interference When new memories affect or ability to recall older ones Probably due to similarity of events in some cases Proactive interference When older memories affect ability to create new ones i.e. if you park in the same place everyday, then someone steals your parking spot.

25. False Memory At times related, but false information can enter into the memory network of an event. Something familiar added Going over and over an imagined situation may be enough to cause fantasy to enter the long-term memory as part of reality Liar who believes his own lies Repeated suggestions by loved ones of an event can cause interference of facts i.e. A child assaulted being questioned constantly

26. Dreaming

27. Dreaming

28. Trauma

29. Children & Trauma Cognitive: shorter attention span, confusion regarding event, location sequencing. Physical: loss of appetite, overeating, bowel/bladder problems, sleep disturbance. Emotional: generalized fear, nervousness, anxiety, irritability, fearful of reminders. Behavioral: bed wetting, thumb sucking, nightmares, repetitive play, anxious attachment, clinging, aggression, disobedience.

30. Children & Trauma Preoccupation with their own actions during the event, specific fears, retelling and replaying the event, impaired concentration and learning, sleep disturbance, concerns about safety(theirs & others), inconsistent bx, somatic complaints, confusion, fearful, concerns for other victims and their family, close monitoring of parent response & recovery.

31. Children & Trauma Detachment, shame, guilt, self consciousness about their fear, vulnerability & other emotional responses, acting out, need for revenge, radical change in world views, life threatening reenactment

32. Children & Trauma Can a traumatic childhood result in learning disabilities?

33. Lasting Effects Trauma doesn�t just affect the person who was exposed. It also affects all the people with whom that person interacts. The more dependent a person is on a trauma survivor, the more deeply he or she will be affected.

34. Post-traumatic Stress Disorder

35. Trauma Cardiac Neurosis Soldier�s irritable heart Shell Shock Hysteria Gross Stress Reaction Transient situation disturbance

36. Post-traumatic Stress Disorder Doctors used to believe that people who experienced an extraordinarily traumatic or life-threatening event should be able to tough it out and move on. Thus the problem with men who suffer from this disorder.

37. Post-traumatic Stress Disorder Re-experiencing distressing images, unwanted memories, nightmares or flashbacks & physical symptoms. Avoidance of reminders of the event, including people, places or things. Hyperarousal, reflected in physiological symptoms: insomnia, irritability, impaired concentration, hypervigilience and increased startle response.

38. Post-traumatic Stress Disorder PET Scans reveal that Vets with PTSD show increased right amygdala activity when exposed to combat movies. MRI studies show that both male combat vets and women survivors of childhood sexual abuse have shrunken hippocampal volumes.

39. In a report using brain imaging in PTSD, combat veterans were found to have an 8% reduction in right hippocampal volume, measured with magnetic resonance imaging (MRI), with no difference in comparison regions including caudate, amygdala and temporal lobe.These findings have been replicated and have been shown to be specific to PTSD and not other anxiety disorders (panic disorder).

40. PTSD Stats Est 5.2 million Americans dx between 18-54yrs old (3.6%). 1 million Vietnam Vets affected. What about recent conflicts? 2x number of women affected vs men. Often co-exist with depression, alcohol or other substance, or other anxiety disorders.

41. Therapy

42. Cognitive Behavior Therapy CBT helps the client first identify the traumatic memory - evaluate their validity, challenge defeating or destructive thoughts, then replace them with a healthy emotional state.

43. Cognitive Behavior Therapy Benefit: Allows integration of trauma memory into conscious memory; associated thoughts are altered to reflect current life space & memories can become manageable (to an extent).

44. Mind/Body Connection

45. Exposure Therapy Derived from the learning theory. Fear is maintained through operant conditioning & the effort to avoid or escape these responses. Avoidance supports the fear

46. Exposure Therapy In order modify the trauma - the memory must be fully reactivated. The client�s ability to decrease fear or anxiety is dependent on the �controlled� reliving of that fear in a safe environment. The client is helped to form a new narrative that places the traumatic memory in the past as opposed to the here and now.

47. Exposure Therapy Art Therapy Play Therapy Stress Inoculation Systematic Desensitization Virtual Reality EMDR Emotional Focused Therapy Tapas Acupressure Therapy

48. Challenges with trauma work Avoidance **Disassociation** Increased drug & alcohol usage Secondary Gain Blocking Flooding

49. Action Plan A: assess for risk (self harm) L: listen non-judgmentally G: give reassurance and info. E: encourage professional help E: encourage self care

50. Lessons I have learned Patience Think outside the box Consider client factors Stressors Health Relationships Finances Only speak when necessary Cognitive interweave Follow the client It�s the client�s therapy Don�t push

51. Another Case Study? Discussion

52. Linear Thinking