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The European Network for Traumatic Stress Training & Practice

The European Network for Traumatic Stress Training & Practice. www.tentsproject.eu. The diagnosis of Posttraumatic Stress Disorder (PTSD). Ask Elklit, Denmark. Glimpses of the history of trauma.

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The European Network for Traumatic Stress Training & Practice

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  1. The European Network for Traumatic StressTraining & Practice www.tentsproject.eu

  2. The diagnosis of Posttraumatic Stress Disorder (PTSD) Ask Elklit, Denmark

  3. Glimpses of the history of trauma • ‘Railway spine’ (1866) was a diagnosis given after railway accidents to describe emotional and personality impact • Pierre Janet (1889) developed a dynamic understanding of trauma that is still valid • Various wars gave name to ‘soldiers’ heart’, ‘shell shock’, ‘combat neurosis’, ‘KZ-syndrom’, ‘Vietnam syndrom’ etc. • This knowledge disappeared in the years following the wars and was ‘reinvented’

  4. Horowitz (1976) • In the book, ”Stress Response Syndrom”, Mardi Horowitz described what he saw as the core dynamics after a traumatic experience: • A long-lasting oscilliation between intrusive reexperiences and denial/avoidance • As Horowitz mainly worked with bereaved people, he paid little attention to arousal symptoms

  5. Split Perceptions Cognitions Actions Emotions Paralysed Hyperstate Model of the consciousness in shock

  6. Scenes in a fixed order Amnesia for Intervening details Model of the perceptual condensation (”etching”) after trauma

  7. Demografis Personality Body state Social group Life events Traumatic event (situational factors) Original shock / defence reflexes (dissociation) *PLEASE ADD AN EXPLANANTION FOR TEACHERS: Defence Attribu- tions Coping (action possibilities) Social support (secondary victimization) Primary appraisal (cognitive-emotional) Hypervigiilance Intrusive recollections Avoidance Psychiatric syndromes (ASD, PTSD etc.) Personality disorders / dysfunctional traits Social changes Psycho-physiological disorders

  8. The DSM-III (a) • Before DSM-III, clinicians and scientists met and tried to find common ground in the symptoms of veterans, rape victims, and battered women. • In 1980, the APA published the first version of PTSD with the three core symptom clusters • Re-experiencing (”intrusive”) • Avoidance • Hypervigiliance (”arousal”)

  9. DSM-III (b) • The clusters consist of items that are descriptive; so are the clusters and there are no expectations about the inherent dynamics as suggested by Horowitz • The Hypervigiliance cluster is a substantial development and addition to the work of Horowitz acknowledging the psychosomatic aspects of experiencing an extreme and threatening situation • Confer the Kardiner (1941) concept of trauma as a ”psychoneurosis”

  10. PTSD today (DSM-IV) • The stressor criteria (both A1 and A2): • A1 ”a life threatening situation, injury or threat to physical integrity” • This can be direct exposure or indirect – witnessing events • The subjective experience is what counts • A2 The person reacts with fear or help-lessness

  11. Re-experiencing (1 symptom) • 1) Recurrent thoughts or perceptions of the event • 2) Recurrent dreams of the event • 3) Acting or feeling as if the event were recurring (flashbacks) • 4) Intense psychological distress and • (5) physiological reactivity when exposed to cues resembling the event

  12. Avoidance 1 (3/7 symptoms) • 1) Avoiding trauma thoughts and feelings • 2) Avoiding activities, places, and people that remind of the trauma • 3) Inability to recall important parts of trauma • 4) Lack of interest in significant activities

  13. Avoidance 2 • 5) Feeling of detachment from others • 6) Restricted affect (no loving feelings) • 7) Sense of a foreshortened future • Note: The two first symptoms are conscious efforts; 4-6 are called ’numbness’ (inability to express feelings and plan for a future). Symptoms not present before the trauma

  14. Hypervigiliance (2/5 symptoms) • Difficulties falling or staying asleep • Irritability or outburst of anger • Difficulty concentrating • Hypervigiliance* • Exaggerated startle response* Note: Symptoms not present before the trauma. The three first may be considered less specific than the two last symptoms*

  15. Duration • Duration of symptoms more than one month • Acute PTSD (less than 3 months) • Chronic (3 months or more) • Delayed (if onset is at least 6 months after the trauma)

  16. Functional impairment • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

  17. PTSD according to WHO • In the ICD-10 diagnostic system, F 43.1 describes PTSD quite differently • The stressor criterion is normative • ”exposed to an unusual threatening or catastrophe stressor that in almost everyone would result in extensive and very distressing reactions” • This downplays the traumas in everyday life

  18. ICD-10 (cont.) • The re-experiencing symptoms corresponds to DSM-IV 2,3, and 4 • Avoidance demands one symptom • Hypervigiliance is like DSM-IV (2/5 symptoms • Amnesia can substitute the hypervigiliance symptoms

  19. ICD-10 (cont.) • Duration: symptoms must be present before 6 months • No functional impairment demands. • The diagnosis can be given after a few days

  20. ICD-10 and DSM-IV compared • Very little research has used the ICD-10 • It is easier to get a PTSD diagnosis from ICD-10 than from DSM-IV • There is little (35%) concordance between diagnoses given by the two systems due to fewer demands in the ICD-10 avoidance clusters and lack of impairment criterion • Epidemiological studies using ICD-10 reveal very few cases of PTSD

  21. Empirical analyses of PTSD • No study has replicated the PTSD structure with the three symptom clusters • Many have suggested that the avoidance group should be divided in conscious avoidance and numbing. • Numbing seems to be closely associated with hypervigiliance where conscious avoidance is associated with re-experiencing

  22. Empirical analyses of PTSD - 2 • Recently, several have suggested that numbing symptoms together the non-specific hypervigiliance symptoms constitute a dysphoria factor not specific to PTSD

  23. Subclinical PTSD • A large number of clients miss one symptom to get the full diagnosis • They typically miss one avoidance symptom • They are often described as having ’sub-syndromal’, ’partial’, or ’subclinical’ PTSD

  24. Subclinical PTSD - 2 • This group often requires clinical attention • It is important to distinguish between those who once had PTSD and are now in partial remission and those never exceeded the full PTSD threshold • For this group is important to consider the functional impairment criterion

  25. PTSD remission • PTSD symptoms often decrease in the weeks and months following a trauma • After three to six months a stabilisation (= little or no change) often comes about • One third will recover fully • One third will have a number of symptoms • One third will become chronic cases

  26. PTSD and other disorders • Having PTSD means that 4 out of 5 will have comorbid (= at the same time) disorders; the most common being: • Anxiety (and phobias) • Depression • Somatoform disorders • Alcohol and drug abuse • Some also develop a personality disorder

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