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Advanced Psychopathology - PSYC961: Kangas, 2007 © Trauma & Posttraumatic Stress Disorder (PTSD): Classification, Assessment & Theories Historical Terms: Nostalgia, shellshock, combat neurosis, & combat fatigue. DSM-I: ‘gross stress reaction’ category ‘individual has been exposed to severe physical demands or extreme emotional stress such as in combat or civilian catastrophe (fire, earthquake, explosion etc)’. DSM-II: no pathological stress category 1980 – DSM III: Posttraumatic Stress Disorder (PTSD). “ stressor that would evoke significant symptoms of distress in almost everyone” [American Psychiatric Association (APA),1980,p.238] DSM Classification 1987 – DSM IIIR: PTSD Criterion A “ an event that is outside the range of normal human experience and that would be markedly distressing to almost anyone ” 1994 – DSM-IV PTSD Criterion A - “the person experienced, witnessed, or was confronted with an event or events that involved actual threatened death or serious injury, or a threat to the physical integrity of self or others”, and which evoked “intense fear, helplessness, or horror” (APA), 1994,p.427) DSM IV: PTSD Criteria (1) Defined by 3 central criteria:1. Re-experiencing - (one or more symptoms) (a) recurrent and intrusive distressing recollections of the event, including images, thoughts, & perceptions. (b) recurrent distressing dreams of the event. (nightmares). (c) reliving the experience, illusions, hallucinations & dissociative flashback episodes. (d) intense distress as exposure to internal/external traumacues. (e) physiological reactivity on exposure to internal/ external cues. DSM IV: PTSD Criteria (2) 2. Marked Avoidance and Emotional Numbing - (three or more symptoms) (a) avoid thoughts, feelings & conversations assoc. with trauma. (b) avoid activities people, places that arouse trauma recollection. (c) traumatic amnesia – inability to recall aspect/s of trauma. (d) withdrawal from activities, interests etc. (e) detachment or estrangement from others. (f) restricted range of affect – blunted affect. (g) sense of foreshortened future. DSM IV: PTSD Criteria (3) 3. Physiological Arousal – (two or more symptoms) (a) sleep disturbances (b) irritability & anger outbursts (c) concentration problems (d) hypervigilance (e) exaggerated startle response Duration of at least one month post-trauma [Criterion E] Acute: symptoms < than 3 months Chronic: symptoms > than 3 months delayed onset: symptoms occur at least 6 mths post-trauma event. Causes clinically significant distress or impairment [Criterion F] DSM IV: Acute Stress Disorder (ASD) New diagnostic criteria Predictor of PTSD - provides opportunity for early intervention Defined by 4 criteria:- central emphasis on dissociative symptoms: emotional numbing reduced awareness of environment derealization depersonalization dissociative amnesia Duration: Occurs within 2 days and 4 weeks post-traumatic event. Will ASD be retained in DSM V? Heavy emphasis on dissociative symptoms unsubstantiated - BUT (a) Dissociation is neither necessary for PTSD, (b) nor optimal predictor of PTSD The ASD diagnosis lacks empirical support: - a substantial number of people develop PTSD without ASD Suggest delete ASD: add V code to PTSD [Refs Bryant, 2007; Spitzer, First & Wakefield, 2007] Current Controversy with PTSD Criteria ‘Conceptual bracket creeping’ (McNally, 2007) call for tightening definition of trauma in PTSD (Spitzer, First & Wakefield, 2007) heavier emphasis on ‘directly experience’ versus ‘confronted’ Non-specificity of PTSD syndrome (Spitzer et al., 2007) Criterion A is essential vs. other anxiety and mood disorders Emphasis on re-experiencing symptoms Eliminate somatic symptoms that overlap with other disorders Criteria C and D integrated into one cluster RISK FACTORS INFLUENCING SEVERITY OF TRAUMATIC STRESS RESPONSES (1) Exposure to a trauma is necessary but NOT sufficient to induce PTSD/trauma responses. Lifetime prevalence rates: 4% - 12% (Kilpatrick, 1992; Resnick et al., 1993) National (US) study: 8% (Kessler et al., 1995, 2005). Important NOT to pathologize normal, transient stress responses in the immediate aftermath of a traumatic event. fear, shock, disbelief, sadness, feelings of loss, grief. Pre-trauma: Female Gender personal & family psychiatric history (esp. anxiety & mood). adverse childhood experiences lower intelligence/ lack of education prior trauma exposure RISK FACTORS INFLUENCING SEVERITY OF TRAUMATIC STRESS RESPONSES (2) Peri-traumatic experiences: dissociative responses elevated heart rate/ physiological indicators (hyperarousal) subjective appraisals trauma severity younger age Post-Trauma: quality of social support. additional life stress coping strategies cultural attitudes. NB: Heterogeneity of responses between individuals & type of trauma (e.g., military vs. civilian events vs. disease related events) PREDICTORS OF PTSD: Empirical Evidence Meta-analytic reviews: (1) Ozer, Best, Lipsey, & Weiss (2003) peri-traumatic dissociation (weighted r = .35) perceived support post-trauma (r = -.28) peritraumatic emotions (r = .26) perceived life threat peri-trauma (r =.26) family history of psychopathology ( r = .17) prior trauma (r =.17) prior adjustment (r=.17) Meta-analytic Reviews (2) (2) Brewin, Andrews, & Valentine (2000) (a) Civilian studies: Life stress (r = .36) Poor social support ( r=.30) Trauma severity (r =.18) Low SES ( r =.15) Female gender; family psychiatric history, childhood adversity (r =.13) Psychiatric history & previous trauma ( r =.11) (b) Military Studies: Poor social support ( r =.43) Life stress (r =.31) Adverse childhood events ( r =.27) Trauma severity ( r =.26) Childhood abuse ( r =.25) Low intelligence ( r =.18) Lack of education (r =.15) Comorbidity (& Differential) Diagnostic Issues Common Comorbid conditions associated with PTSD: Depression (suicide risk) Other forms of anxiety (esp. Panic Disorder) Substance Abuse (alcohol & drugs) Severe cases: Personality Disorders & aggression Common symptoms: guilt shame/ humiliation anger de-moralisation/ “mental defeat” (Ehlers & Clark, 2000) grief Assessment Issues & Considerations (1) material covered may be distressing. inform client that assessment and initial stages of therapy may exacerbate symptoms pivotal to ‘normalize’ trauma experience Clinician’s role – establish rapport, trust, supportive & safe environment. Assessment Issues (2) Distinguish b/w acute (ASD) and chronic trauma (PTSD) * Reference source for following assessment considerations: Bryant & Harvey, 2000. 1. Motivation: * Self-referred vs. coerced via others; 2. Organisational Issues: * need to be aware of organizational structure & attitudes of subculture. Assessment Issues (3) 3. The Assessment Context/Environment: * may activate trauma-cues or may be construed as safe – hence exaggerate vs. downplay trauma symptoms. 4. Ongoing Stressors: * Common secondary stressors = physical injury, pain, loss (financial), & legal procedures. * Need for comprehensive assessment to index all ongoing stressors post-trauma. Assessment Issues (4) 5. Previous Trauma & Psychiatric History: “Even those seeking mental-health treatment may not recognize the relevance of past trauma to their present problems and will NOT discuss their trauma history unless explicitly asked to” (Solomon & Johnson, 2002, p.957). 6. Comorbidity: * especially depression; * other anxiety, substance-abuse, & somatoform disorders; * Suicide risk assessment is critical at initial assessment. Assessment Issues (5) 7. Dissociative & Avoidance Symptoms: coping mechanisms: E.g., distraction, thought suppression, medication, ‘safety behaviours”, ritualistic behaviours (i.e., mantras) 8. Timing of assessment: *time elapsed since trauma; *determine if trauma-event & 2ndary stressors have ceased; 9. Meaning of trauma: * client’s meaning of traumatic experience; Assessment Issues (6) 10. Social Support: * current availability – quality of support; 11. Additional considerations: (a) current medications (sleeping, anxiolytics, anti-depressants); (b) alcohol & drug use – current & previous history; (c) legal procedures pending. (d) malingering Assessment Measures (1) A. Acute Stress Disorder (ASD) Measures: 1. Structured Interviews: (a) Acute Stress Disorder Interview (ASDI: Bryant, Harvey, Dang & Sackville, 1998) – validated against DSM-IV criteria. 2. Self-Report Measures: (a) Stanford Acute Stress Reaction Questionnaire (SASRQ: Cardena, Koopman, Classen, Waelde, & Spiegel, 2000). (b) Acute Stress Disorder Scale (ASDS: Bryant, Moulds, & Guthrie, 2000). Assessment Measures (2) B. PTSD Measures: 1. Structured Interviews: Some well-validated measures (a) Structured Clinical Interview for DSM-IV – PTSD Module (Spitzer, Gibbon, & Williams, 1996). (b) The Clinician Administered PTSD Scale (CAPS: Blake et al., 1995). (c) The PTSD Symptom Scale Interview (PSS-I: Foa et al., 1993). 2. Self-Report Measures: (a) Posttraumatic Diagnostic Scale (PTDS: Foa et al., 1997). (b) Davidson Trauma Scale (DTS: Davidson et al., 1997). (c) Mississippi Scale for Combat-Related PTSD (Keane, Caddell, & Taylor, 1988). (d) Impact of Events Scale – Revised Version (IES-R: Weiss & Marmar, 1996) – NB *non-diagnostic* Assessment Measures (3) B. PTSD Measures - continued: 3. Dysfunctional Beliefs: (a) Posttraumatic Cognitions Inventory (PTCI) (Foa et al., 1999). (b) World Assumptions Scale (WAS: Janoff-Bulman, 1989). 4. Additional Measures: (a) Depression BDI-II (b) Dissociative Experiences Scale (Bernstein & Putnam, 1986) (c) Distress DASS; SCL-R90 or BSI; TRAUMA THEORIES (1) • Theories influence conceptualisation & approach to treatment. 1. Biological theories - Based on animal models (i) Amygdala & Noradrenergic dysregulation hyperarousal symptoms (i) Medial prefrontal cortex - inhibition of amygdala by cortex fear extinction - PTSD: insufficient inhibition re-experiencing symptoms (iii) Hippocampal controversy: Does stress damage brain? - cortisol (glucocorticoids) learning and memory - smaller hippocampi in PTSD patients decline in memory - BUT may be predisposing factor rather than stress-induced TRAUMA THEORIES (2) 2. Schema-based theories: (a) Horowitz’s stress response theory (1976,1986). New information (i) assimilated, or (ii) accommodated into memory schemas Resolution requires oscillation between avoidance & intrusions Limitations of theory (Cf. Brewin & Holmes, 2003): 1. flashbacks vs. ordinary memories 2. does not explain peri-trauma reactions 3. successful recovery vs. successful avoidance. TRAUMA THEORIES (3) 2(b). Janoff-Bulman’s Theory of Shattered Assumptions: 3 common assumptions influencing processing of trauma: (a) world is benevolent (b) world is meaningful reliable rules & principles of safety (c) self is worthy people are good, moral, well-intentioned. TRAUMA THEORIES (4) 3. Behavioural - Conditioning Theory: Mowrer’s (1960) 2-factor learning theory neutral stimuli in trauma context acquire fear-eliciting responses (CS) via association with the US. - Repeated exposure extinction - BUT, extinction fails if use avoidance or distraction Strengths – (i) explains maintenance of symptoms, (ii) central role of avoidance. Limitations – (i) absence of cognitive process; (ii) does not differentiate between different anxiety TRAUMA THEORIES (5) 4. Cognitive Models: (a) Information – Processing Theories: Lang’s (1977) conceptual model of emotion: - trauma memories represented by 3 types of propositional information: (1) stimulus, (2) response, & (3) meaning. Edna Foa and her colleagues (1986, 1989, 1995) - “Emotional processing theory” - Trauma formation of fear network. - Trauma symptoms network info incompatible with preexisting memory structures. TRAUMA THEORIES (6) [Foa et al’s theory – continued] - Trauma Resolution: (1) activation & emotional engagement of trauma memories; (2) organization of trauma narratives; & (3) correction of dysfunctional cognitions. Treatment implications: emphasis on exposure based procedures. Strengths: (1) explains cognitive processes; (2) associated with highly effective treatment approach. Limitation: memory inhibition research vs. memory modification TRAUMA THEORIES (7) (b) Dual Representation Theory (Brewin et al., 1996). - Trauma memories dissociated from ordinary memories. - Hence dual memory symptoms operating in parallel. (1) Verbally Accessible Memory (VAMs) = oral or written narrative memories; deliberatively retrieved; (2) Situationally Accessible Memories (SAMs) = explain flashback experiences as SAMs triggered involuntarily by situational trauma - cues. TRAUMA THEORIES (8) (b) Dual Representation Theory – [Continued] Implications of theory = PTSD is a hybrid disorder: (1) resolution of negative cognitions (2) management of flashbacks. Limitations: 1. Controversial – no compelling evidence of fragmented VAMS 2. Heavy focus on flashbacks – no explanation for more common PTSD symptoms 3. No conclusive evidence that SAMs NOT stored in VAMs system minimal info (thus evidence) on how 2 systems interact TRAUMA THEORIES (9) (c) Ehler & Clark’s (2000) Cognitive Model: (a) Traumatized individuals focus on data-driven/sensory processing vs. conceptual driven processing (b) Associated with autobiographical memory deficits lack contextualisation & poor elaboration (c) Excessive negative appraisals (d) Maladaptive coping strategies TRAUMA THEORIES (10) (c) Ehler & Clark’s (2000) Cognitive Model - conmtinued: * Limitations (cf: Taylor, 2006): (a) less parsimonious than other cog-behav models (b) Questionable proposition – emphasis on data-driven processes (c) Does not explain role of numbing and dissociative symptoms (d) Does not explain why only a small proportion of people exposed to life threat events develop PTSD Common Treatment Interventions for Trauma A. Psychological Debriefing/ Crisis Intervention B. Pharmacotherapy C. Cognitive Behavioural Therapy (CBT) Approaches: (1) Exposure Therapies: (a) Systematic Desensitization (b) Prolonged Imaginal and Invivo Exposure (2) Combined Approaches: (a) Exposure and Cognitive Therapy (b) Cognitive Processing Therapy (CPT: Resick & Schnicke, 1992) (3) Anxiety/Stress Management Programs (4) Eye Movement Desensitization & Processing (EMDR) D. Psychodynamic Therapies E. Integrative Approaches. Common Treatment Interventions for Trauma (II) Empirically supported treatments for PTSD & recommended by the International Society for Traumatic Stress Studies (ISTSS): CBT: Foa et al’s PE (exposure) therapy Cognitive therapy (e.g., Resick et al., 2002) Interpersonal psychotherapy (e.g., Bleberg & Markowitz, 2005) Minimal evidence base for psychodynamic & supportive counselling [Ref: Nemeroff et al., 2006] REFERENCES Blake, D. D., Weathers, F. W., Nagy, L. et al. (1995). The development of a clinician administered PTSD scale. Journal of Traumatic Stress, 8, 75-90. Brewin, C.R., Andrews, B., & Valentine, J.D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in traumaexposed adults. Journal of Consulting and Clinical Psychology, 68, 748-766. Brewin, C.R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review, 103, 670-686. Bryant, R.A. (2007). Does dissociation further our understanding of PTSD? Journal of Anxiety Disorder, Bryant, R.A., & Harvey, A.G. (2000). Acute Stress Disorder A Handbook of Theory, Assessment, and Treatment. American Psychological Association. Bryant, R. A., Harvey, A. G., Dang, S. T., & Sackville, T. (1998). Assessing acute stress disorder: Psychometric properties of a structured clinical interview. Psychological Assessment, 10, 215-220. Cardeña, E., Koopman, C., Classen, C., Waelde, L. C., & Spiegel, D. (2000). Psychometric properties of the Stanford Acute Stress Reaction Questionnaire (SASRQ): A valid and reliable measure of acute stress. Journal of Traumatic Stress, 13, 719-734. Ehlers, A., & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319345. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured Clinical Interview for DSM-IV Axis I DisordersClinician Version. NY: American Psychiatric Press. Foa, E.B., & Hearst-Ikeda. (1995). Emotional dissociation in response to trauma: An information-processing approach. In L.K. Michelson & W.J. Ray (Eds). Handbook of dissociation: Theoretical and clinical perspectives (pp.207-222). New York: Plenum Press. Foa, E.B., Riggs, D.S., Dancu, C.V., & Rothbaum, B.O. (1993). Reliability and validity of a brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6, 459-473. Horowitz, M.J. (2001). Stress response syndromes (4th ed). Northvale, NJ: Jason Aronson. Janoff-Bulman, R. (1992). Shattered assumptions. New York: Free Press. Keane, T.M., Caddell, J.M., & Taylor, K. (1988). Mississippi Scale for Combat-Related Post-traumatic Stress Disorder: three studies in reliability and validity. Journal of Consulting and Clinical Psychology, 56, 85-90. McNally, R.J. (2007). Can we solve the mysteries of the National Vietnam Veterans Readjustment Study. Journal of Anxiety Disorder, Nemeroff, C.B., Bremnar, J.D., Foa, E.B., Mayberg, H.S., North, C.S., & Stein, M. B. (2006). Posttraumatic stress disorder: A stateof-the-science review. Journal of Psychiatric Research, 40, 1-21. Ozer, E.J., Best, S.R., Lipsey, T.L., Weiss, D.S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychological Bulletin, 129, 52-73. Spitzer, R.L., First, M.B., & Wakefield, J.C. (2007). Saving PTSD from itself in DSM-IV. Journal of Anxiety disorders, Taylor, S. (2006). Clinician’s guide to PTSD a cognitive-behavioral approach. New York: The Guildford Press.