Making Sense of the Complexities of Trauma

1. Making Sense of the Complexities of Trauma Heather Hartman-Hall, Ph.D. 2012

2. Training Objectives Participants will be able to… • Identify diagnostic challenges in working with clients who have experienced trauma. • Understand how current symptoms may reflect adaptations to traumatic experiences. • Describe important features of a complex trauma syndrome.

3. Training Objectives (cont.) • Identify several strategies for helping clients manage self-injurious and suicidal behaviors. • Understand vicarious traumatization and the importance of clinician self-care.

4. PART ONE: Understanding Complex Trauma Syndromes

5. “Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. When the force is that of nature, we speak of disasters. When the force is that of other human beings, we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning.” – Judith Herman, Trauma and Recovery, 1997

6. PREVALENCE AND ETIOLOGY

7. Prevalence While the criteria for PTSD diagnosis have gotten stricter since 1980, our ability to assess for and detect PTSD has improved; the overall prevalence has remained fairly stable in that period

8. Prevalence (cont.) PTSD is still likely underdiagnosed, particularly in several demographic groups (e.g., Brunet, 2007) In many settings, trauma not routinely assessed as part of intakes (van der Kolk et al., 2005)

9. Prevalence (cont.) • Estimates for exposure to potentially traumatizing events in the US tend to range around 70% of people surveyed • CDC “ACE” study (2009) • >26K non-institutionalized US adults in 5 states • 8.7% reported 5 or more ACEs • Sexual abuse: 17.2% for women, 6.7% for men • ACEs associated with “multiple mental and physical health problems”

10. Prevalence (cont.) • Prevalence rates for PTSD vary depending on the group surveyed; for the general US population lifetime prevalence is estimated to be 6.8-8%

11. Prevalence (cont.) • National Comorbidity Survey Replication (NCS-R), conducted between 2001 and 2003 (Gradus, 2007) • Nationally representative sample of Americans aged 18 years and older • 5K+ participants assessed for PTSD by interview using DSM-IV criteria • Lifetime prevalence of PTSD est. at 6.8% • Among women: 9.7%, men: 3.6%

12. Prevalence (cont.) • NCS-R yielded estimates similar to first National Comorbidity Survey (early 1990’s):

13. Prevalence (cont.) • DSM-IV-TR: Community-based studies indicate about 8% lifetime prevalence for PTSD adults in the US

14. Prevalence (cont.) • Random sample of 4,008 US women (Resnick, 1993) • Lifetime exposure to any type of civilian traumatic event: 69% • 36% endorsed exposure to crimes that included sexual or aggravated assault or homicide of a close relative or friend • Lifetime prevalence of PTSD:12.3% • significantly higher among crime vs noncrime victims (25.8% vs 9.4%).

15. Prevalence (cont.) • Study of 152 women aged 18-45 consecutively seen for routine gynecological care in family physician office (Sansone, et al.,1995) • Traumatic experiences were reported by 70.7% • Sexual abuse reported by 25.8% • Physical abuse reported by 36.4% • Emotional abuse reported by 43.7% • Physical neglect reported by 9.3% • Witnessing of violence reported by 43.0%

16. Prevalence (cont.) • Random sample of 1008 adult residents of Manhattan 5-8 weeks after September 11, 2001 terrorist attacks (Galea, et al., 2002) • 7.5% reported symptoms consistent with a diagnosis of current PTSD related to the attacks • 20% in residents who lived near World Trade Center • Predictors of PTSD: Hispanic ethnicity, prior stressors, a panic attack during or shortly after the events, proximity to WTC, and loss of possessions due to the events. • 9.7% reported symptoms of depression

17. Prevalence (cont.) • Interviews of 810 adult residents in southern Mississippi (random selection of addresses in each of 3 strata), 18-24 months after Hurricane Katrina (Galea, et al. 2008) • 22.5% diagnosed with PTSD in that period • Risk factors included: • Being female • Financial loss • Low social support • Post-disaster stressors/traumas

18. Prevalence – Complex PTSD • Full syndrome estimated <1% in nonclinical population • Sub-syndrome symptoms of CPTSD more common and are associated with childhood trauma

19. Prevalence – Complex PTSD (cont.) • van Dijke, et al. (2011) found 10-38% of psychiatric inpatients met criteria for Complex PTSD • In one small study of forensic inpatients in Germany, 28% were diagnosed with CPTSD; 44% lifetime prevalence

20. Interpersonal Trauma and PTSD • Interpersonal trauma is associated with higher rates of PTSD than other types of trauma (accidents, disasters, etc.) • Being victimized by criminal acts more associated with PTSD symptoms • Interpersonal traumas experienced in childhood increase likelihood of PTSD, and of victimization later in life

21. Gender Differences • National Comorbidity Survey indicated that more males than females in the US experience trauma, but more females develop PTSD • Lifetime prevalence of PTSD for women is about twice that of men • Some studies suggest PTSD lasts longer in females than males

22. Gender Differences (cont.) • Women more likely to be exposed to interpersonal forms of trauma (Lilly & Valdez, 2012) • Females typically report more sexual abuse than males • Experience of interpersonal trauma may be more predictive of later PTSD than gender

23. Gender Differences (cont.) • Teenage boys in particular rarely report sexual abuse, particularly by a woman • Guilt/shame • “Rite of passage” • Normalized or even viewed as positive by peers/other adults

24. Gender Differences (cont.) • Males may be less likely to seek treatment • Gender of therapist may be important • Differences in symptom presentation? • Culturally-imposed gender roles (e.g., Evans & Sullivan, 1995)

25. Special Populations • “…many or even most psychiatric patients are survivors” of abuse (Herman, 1997) • Some estimates suggest 1/3-1/2 of people in treatment for substance abuse have PTSD • Lifetime exposure to trauma has been reported to be higher in adult and juvenile offenders • Especially child abuse (Spitzer, et al., 2006)

26. Early Risk • “Ideally, parenting is the essential buffer against trauma” (Allen, 1995) • When a small child’s needs are met predictably by his environment, more likely to develop secure attachment (Schore, 2002) • May affect development of the central nervous system and the limbic system • Secure attachment includes the assumption that “homeostatic disruptions will be set right”

27. Early Risk (cont.) • Childhood abuse often occurs within the context of neglect, deprivation, and emotional invalidation (Briere, 1996) • Acts of both commission and omission (Korn & Leeds, 2002): • Sexual, physical, emotional abuse • Witnessing violence • Unmet physical and emotional needs • Parental unavailability • Failure to protect by caregivers • Childhood separations

28. Early Risk (cont.) • Increasing evidence that childhood trauma puts people at higher risk for mental illness and maladaptive stress responses in adulthood • New research using brain scans shows structural changes (particularly in areas of the brain related to stress response) • “a violation of and challenge to the fragile, immature and newly emerging self (Ford & Courtois, 2009)

29. Early Risk (cont.) • Childhood traumas can “block or interrupt the normal progression of psychological development in periods when a child…is acquiring the fundamental psychological and biological foundations necessary for all subsequent development (Ford, 2009) • Brain shifts from “learning” functions to “survival” functions

30. Early Risk (cont.) • When a child is betrayed (e.g., abused or neglected) by a caregiver, child still needs caregiver to survive • May remain unaware of the betrayal (Kaehler & Freyd, 2011) • Dissociation • Blame self rather than caregiver • Rationalize/excuse the abuser

31. Risk Factors/Resilience • Most traumas don’t result in mental illness • DSM-IV-TR: “severity, duration, and proximity of an individual’s exposure to the traumatic event are the most important factors” in risk for PTSD… “some evidence that social supports, family history, childhood experiences, personality variables, and pre-existing mental disorders may influence” development of PTSD

32. Common Reactions to Frightening Experiences • Shock • Anxiety/worry • Irritability/anger • Changes in eating or sleeping habits • Physical problems or illness • Apathy/loss of interest in usual activities • Feeling “jumpy” Most people experience some temporary interference in usual functioning after a traumatic experience.

33. Fight or Flight Response • Mammals have developed response to threat through evolution • Sympathetic nervous system • Once the response is set off, hormones released into the body create various changes to prepare the body for vigorous action • Increased heart rate, constriction of blood vessels, tunnel vision, reduced GI and sexual functioning

34. Fight or Flight Response (cont.) • “Fight or Flight” represents a complex stress response • Decades of stress research (e.g. Bracha, et al. 2004) have illuminated four fear responses that occur in order in the face of a threat • Initial freeze response • Attempt to flee • Attempt to fight • Tonic immobility • “Freeze, flight, fight, fright response”

35. Fight or Flight Response (cont.) • Stress response begins with the individual’s appraisal of the event and how it may affect him or her • Various individual and situational factors will influence appraisal • Likely an automatic and even unconscious process • Includes whether individual has resources to cope with stressor

36. Fight or Flight Response (cont.) • Physiologically, the response to rage and fear are the same • May be an adaptive response to single-incident, intense stress, but can become problematic • When continuously activated • When natural response is blocked • Loss of ability to return to baseline state of physical calm or comfort

37. Adaptations to Trauma • A natural response to an overwhelming experience • Strategies that are adaptive in a crisis can backfire when trauma is ongoing or when self-regulation doesn’t come back online • “natural, self-protective efforts gone awry” (Allen, 1995)

38. Long-Term Effects of Trauma • Physiological changes • Dysregulated emotions • Disruption of relationships • Damaged/changed view of self • Changes in world view/belief system • Break down of coping strategies • Altered perceptions

39. Diagnostic Challenges

40. A Confusing Picture What are the likely diagnoses for each of the following symptom clusters?

41. Numerous hospitalizations, history of cutting arms repeatedly, has trouble trusting others but is afraid to be alone. Appears withdrawn, suspicious of others, occasionally appears to be responding to internal stimuli. Hypersexuality, risk-taking, substance abuse, insomnia, weight loss.

42. Episodic confusion, poor memory, inability to attend to conversations, little spontaneous speech, low activity level. Flat affect, unable to think of anything good that might happen in the future, low energy, finds little enjoyment in activities once enjoyed. Reports hearing a voice that repeats insults and phrases such as “You should die.” Reports sometimes feeling that she leaves her body and looks down at herself from the sky.

43. Diagnostic Challenges • Misdiagnosis – “bewildering array of symptoms” (Herman, 1997) • Symptoms and functioning often vary over time and across situations • Self-report might not include information about trauma • Strengths/abilities might mask difficulties or make impairment less obvious • Trauma disorders may not be considered, particularly in some settings

44. Diagnostic Challenges (cont.) • Comorbidity of trauma with other disorders • One large study: 84% of people with PTSD met criteria for at least one other psychiatric disorder • Major depression • Substance abuse • Other anxiety disorders • Schizophrenia • Dissociative disorders • Personality disorders • Comorbid somatic problems also very common

45. Cultural Factors • DSM-IV-TR emphasizes importance of considering culture in diagnosis • Research on trauma in mainstream US population might not generalize to other cultures(Carlson, 1997) • Some evidence of higher rates of trauma and/or more severe symptoms among people from ethnic minority groups and deaf people(Davis, et al. 2011; Ford 2012) • SES status and its associated stressors may play a role

46. Cultural Factors (cont.) • Possible differences in symptom presentation (Schlid & Dalenberg, 2012; Brunet, 2007; Frueh, et al., 2002; Sue & Sue, 1987) • Asian cultures more likely to present with physical symptoms as a trauma response • African-American combat veterans with PTSD may present with more psychotic symptoms • Trauma symptoms may present differently in deaf vs. hearing people

47. Axis I Disorders Associated with Trauma

48. Diagnoses Commonly Associated with Trauma • Post-Traumatic Stress Disorder (PTSD) • Acute Stress Disorder • Borderline Personality Disorder • Dissociative Disorders • Substance Abuse/Dependence • Eating Disorders • Other anxiety, mood, somatoform, personality disorders

49. PTSD • Symptoms usually begin within 3 months of traumatic experience, but may be a delay of months or even years • Three clusters of symptoms: • Re-experiencing • Avoidance/numbing • Hyperarousal • Bi-phasic condition that alternates between reliving the overwhelming experience, and avoiding thoughts/feelings associated with trauma

50. PTSD (cont.) DSM-IV-TR Criterion A: 1.The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. 2.The person's response involved intense fear, helplessness, or horror. (In children, may be expressed instead by disorganized or agitated behavior)