Download Incidence rates of trauma in children, adolescents, and adults

Advanced Trauma
Interventions for Adolescent
with Co-Occurring Mental
Health Disorders
Presented By:
John P. Seasock LPC, PsyD
Specialist/Consultant
PCCYFS 2012 Annual Spring Conference
Presented by: John P. Seasock
LPC, PsyD
Specialist/Consultant
Renaissance Psychological and
Counseling Corporation
RP C
PCCYFS 2012 Annual
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2
138 Sharpe Street
Kingston, PA 18704
Phone: 570-237-5440
Fax: 570-287-2256
[email protected]
Incidence rates of trauma in
children, adolescents, and adults
A few studies of the general population have
been conducted that examine rates of exposure
and PTSD in children and adolescents and
adults. Results from these studies indicate:
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• 15 to 43% of females and 14 to 43% of males have
experienced at least one traumatic event in their
lifetime.
• Of those children, adolescents and adults who
have experienced a trauma, 3 to 15% of females
and 1 to 6% of males could be diagnosed with
PTSD.
• Rates of PTSD are much higher in children and
adolescents recruited from at-risk samples.
• The rates of PTSD in these at-risk children and
adolescents vary from 3 to 100%.
Identification of “traumatic
experiences”
• A diagnosis of PTSD means that an individual
experienced an event that involved a threat to
one's own or another's life or physical
integrity and that this person responded with
intense fear, helplessness, or horror.
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• Persons may be diagnosed with PTSD if they
have survived natural and man made
disasters such as floods; violent crimes such
as kidnapping, rape, murder of a loved one,
sniper fire, school shootings, motor vehicle
accidents, plane crashes; severe burns;
exposure to community violence; war; peer
suicide, sexual and physical abuse and so on.
Role of cognitions/beliefs in
interpreting traumatic experiences
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• Because most trauma survivors don't know how
trauma usually affects people, they often have
trouble understanding what is happening to them.
• They may think it is their fault that the trauma
happened, that they are going crazy, or that there
is something wrong with them because other
people who were there don't seem to have the
same problems.
• The interpretation and appraisal of the
experienced trauma is the key to whether a
person continues on to develop symptoms of
PTSD or resolves any emotional conflict after a
period of stress (acute).
• The complex disorder of PTSD is a disorder that
begins with anxiety producing “thoughts”
Reactions of children & adolescents
to traumatic experiences
• The diagnosis of Posttraumatic Stress
Disorder (PTSD) was formally recognized as a
psychiatric diagnosis in 1980.
• At that time, little was known about what
PTSD looked like in children and adolescents.
• Today, we know children and adolescents are
susceptible to developing PTSD, and we know
that PTSD has different age-specific features.
• We are beginning to develop child-focused
interventions
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Distinctive Neurobiological and
Physiological changes in
traumatized individuals
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• PTSD results from several neurobiological and
physiological changes.
• It is accompanied by neurobiological changes
in the central and autonomic nervous systems.
• These changes may include altered brainwave
activity, decreased volume of the hippocampus
and abnormal activation of the amygdala.
• These psycho-physiological alterations tend to
lead to abnormal levels of key hormones
involved in the body’s response to stress.
• People with PTSD generally have increased
thyroid function, lower cortisol levels and
higher norepinephrine and epinephrine levels.
Risk Factors/Protective Factors
There are three factors that have been
shown to increase the likelihood that
children will develop PTSD. These factors
include :
• The severity of the traumatic event,
• The parental reaction to the traumatic
event,
• The physical proximity to the traumatic
event.
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There are several other factors
that affect the occurrence and
severity of PTSD:
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• Family support and parental coping have also
been shown to affect PTSD symptoms in
children.
• Children and adolescents who are farther away
from the traumatic event report less distress.
• Rape and assault are more likely to result in
PTSD than other types of traumas.
• Additionally, if an individual has experienced a
number of traumatic events in the past, those
experiences increase the risk of developing
PTSD.
There are several other factors that
affect the occurrence and severity of
PTSD, cont.
• Several studies suggest that girls are more
likely than boys to develop PTSD.
• While some studies find that minorities report
higher levels of PTSD symptoms, researchers
have shown that this is due to other factors
such as differences in levels of exposure.
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There are several other factors that
affect the occurrence and severity of
PTSD, cont.
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• It is not clear how a child’s age at the time of
exposure to a traumatic event impacts the
occurrence or severity of PTSD. Differences
that do occur may be due to differences in the
way PTSD is expressed in children and
adolescents of different ages or developmental
levels
• People who have PTSD also have strengths,
interests, commitments, relationships with
others, past experiences that were not
traumatic, desires, and hopes for the future.
Diagnostic Criteria for Acute
Stress Disorder (DSM-IV-TR)
A. The person has been exposed to a
traumatic event in which both of the
following were present:
1. The person experienced, witnessed, or was
confronted with an event or events that
involved actual or threatened death or
serious injury, or a threat to the physical
integrity of self or others
2. The person’s response involved intense
fear, helplessness, or horror
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Diagnostic Criteria for ASD
(DSM-IV-TR), cont.
B. Either while experiencing or after
experiencing the distressing event, the
individual has three or more) of the
following dissociative symptoms:
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1. A subjective sense of numbing, detachment,
or absence of emotional responsiveness
2. A reduction in awareness of his or her
surroundings (e.g., “being in a daze”)
3. Derealization
4. Depersonalization
5. Dissociative amnesia (i.e., inability to recall
an important aspect of the trauma
Diagnostic Criteria for ASD
(DSM-IV-TR), cont.
C. The traumatic event is persistently reexperienced in at least one of the following
ways: recurrent images, thoughts, dreams,
illusions, flashback episodes, or a sense of
reliving the experience: or distress on
exposure to reminders of the traumatic
event.
D. Marked avoidance of stimuli that arouse
recollections of the trauma (e.g., thoughts,
feelings, conversations, activities, places,
people)
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Diagnostic Criteria for ASD
(DSM-IV-TR), cont.
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E. Marked symptoms of anxiety or increased
arousal (e.g., difficulty sleeping, irritability,
poor concentration, hyper-vigilance,
exaggerated startle response, motor
restlessness)
F. The disturbance causes clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning or impairs the individual’s
ability to pursue some necessary task, such
as obtaining necessary assistance or
mobilizing personal resources by telling
family members about traumatic
experience.
Diagnostic Criteria for ASD
(DSM-IV-TR), cont.
G. The disturbance lasts for a minimum of 2
days and a maximum of 4 weeks and
occurs within 4 weeks of the traumatic
event.
H. The disturbance is not due to the direct
physiological effect of a substance (e.g., a
drug of abuse, a medication) or a general
medical condition, is not better accounted
for by Brief Psychotic Disorder, and is not
merely an exacerbation of a preexisting
Axis I or Axis II disorder.
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Diagnostic Criteria for Post
Traumatic Stress Disorder
(DSM-IV-TR)
A. The person has been exposed to a
traumatic event in which both of the
following were present:
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1. The person experienced, witnessed, or was
confronted with an event or events that
involved actual or threatened death or
serious injury, or a threat to the physical
integrity of self or others.
2. The person’s response involved intense
fear, helplessness, or horror. In children,
this may be expressed instead by
disorganized or agitated behavior.
Diagnostic Criteria for PTSD (DSM-IV-TR)
B. The traumatic event is persistently reexperienced in one (or more) of the following
ways:
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1. Recurrent and intrusive distressing recollections of the event,
including images, thoughts, or perceptions. Note: In young
children, repetitive play may occur in which themes or
aspects of the trauma are expressed.
2. Recurrent distressing dreams of the event. Note: In children,
there may be frightening dreams without recognizable
content.
3. Acting or feeling as if the traumatic event were recurring
(includes a sense of reliving the experience, illusions,
hallucinations, and dissociative flashback episodes, including
those that occur on awakening or when intoxicated.) Note: in
young children, trauma-specific reenactment may occur.
4. Intense psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic event.
5. Physiological reactivity on exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic
event.
Diagnostic Criteria for PTSD
(DSM-IV-TR), cont.
C. Persistent avoidance of stimuli associated with the
trauma and numbing of the general responsiveness
(not present before the trauma), as indicated by
three (or more) of the following:
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1. Efforts to avoid thoughts, feelings, or conversations
associated with the trauma
2. Efforts to avoid activities, places, or people that arouse
recollections of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant
activities
5. Feelings of detachment or estrangement from others
6. Restricted rang of affect (e.g., unable to have loving
feelings)
7. Sense of a foreshortened future (e.g., does not expect to
have a career, marriage, children, or a normal lifespan)
Diagnostic Criteria for PTSD
(DSM-IV-TR), cont.
D. Persistent symptoms of increased arousal
(not present before the trauma), as
indicated by two (or more) of the following:
1.
2.
3.
4.
5.
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Difficulty falling or staying asleep
Irritability or outburst of anger
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
Diagnostic Criteria for PTSD
(DSM-IV-TR), cont.
E. Duration of the disturbance (symptoms
in Criteria B, C and D) is more than 1
month
F. The disturbance cause clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning
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Specify if:
• Acute: if duration of symptoms is less
than 3 months
• Chronic: if duration of symptoms is 3
months or more
• With Delayed Onset: if onset of
symptoms is at least 6 months after the
stressor
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Diagnosis of Post Traumatic
Stress Disorder in children and
adolescents
• Researchers and clinicians are beginning
to recognize that PTSD may not present
itself in children the same way it does in
adults Criteria for PTSD now include agespecific features for some symptoms.
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Very young children may present
with few PTSD symptoms
• This may be because eight of the PTSD
symptoms require a verbal description
of one's feelings and experiences.
• These children may also display
posttraumatic play in which they repeat
themes of the trauma.
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• Children may lose an acquired
developmental skill (such as toilet
training) as a result of experiencing a
traumatic event.
Elementary school-aged children
may not experience visual
flashbacks or amnesia for aspects
of the trauma.
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• They experience "time skew" and "omen
formation," which are not typically seen in
adults.
• School-aged children also reportedly exhibit
posttraumatic play or reenactment of the
trauma in play, drawings, or verbalizations.
• Posttraumatic play is different from
reenactment in that posttraumatic play is a
literal representation of the trauma, involves
compulsively repeating some aspect of the
trauma, and does not tend to relieve anxiety.
Adolescents may begin to more
closely resemble PTSD in adults.
• Adolescents are more likely to engage in
traumatic reenactment, in which they
incorporate aspects of the trauma into
their daily lives.
• Adolescents are more likely than younger
children or adults to exhibit impulsive
and aggressive behaviors.
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Vicarious Trauma
• This term refers to the stress and trauma
reactions that can occur in response to
witnessing or hearing about traumatic
events that have happened to others. In
these cases, other people are the victims,
and you see them undergoing suffering,
or hear about traumatic events that have
happened to them.
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Co-Occurring Disorders and Post
Traumatic Stress Disorder
• When these symptoms are present for a
prolonged period of time, they often
begin to develop into “Co-Occurring
Disorders” that may begin to take on a
life of their own and begin to appear
independent of any identifiable PTSD
symptomology.
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Re-experiencing Symptoms
• Trauma survivors commonly continue reexperiencing their traumas. Reexperiencing means that the survivor
continues to have the same mental,
emotional, and physical experiences that
occurred during or just after the trauma.
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Mentally re-experiencing the
trauma can include:
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• Upsetting memories such as images or other
thoughts about the trauma.
• Feeling as if it the trauma is happening again
("Flashbacks").
• Bad dreams and nightmares.
• Getting upset when reminded about the trauma (by
something the person sees, hears, feels, smells, or
tastes).
• Anxiety or fear - feeling in danger again.
• Anger or aggressive feelings or feeling the need to
defend oneself.
• Trouble controlling emotions because reminders
lead to sudden anxiety, anger or upset.
• Trouble concentrating or thinking clearly.
People also can have physical
reactions to trauma reminders
such as:
• Trouble falling or staying asleep.
• Feeling agitated and constantly on the
lookout for danger.
• Getting very startled by loud noises or
something or someone coming up on you
from behind when you don't expect it.
• Feeling shaky and sweaty.
• Having your heart pound or having trouble
breathing.
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Avoidance Symptoms:
• Because thinking about the trauma and
feeling as if you are in danger is so
upsetting, people who have been through
traumas want to avoid reminders of trauma.
Ways of avoiding thoughts, feelings, and
sensations associated with the trauma can
include:
•
•
•
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Actively avoiding trauma-related thoughts
and memories.
Avoiding conversations and staying away
from places, activities, or people that might
remind you of trauma.
Trouble remembering important parts of
what happened during the trauma.
Avoidance symptoms, cont.
•
•
•
•
•
•
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•
•
•
•
"Shutting down" emotionally or feeling
emotionally numb.
Trouble having loving feelings or feeling
any strong emotions.
Finding that things around you seem
strange or unreal.
Feeling strange or "not yourself".
Feeling disconnected from the world
around you and things that happen to you.
Avoiding situations that might make you
have a strong emotional reaction.
Feeling weird physical sensations.
Feeling physically numb.
Not feeling pain or other sensations.
Losing interest in things you used to enjoy
doing.
“Secondary” and Associated PTSD
Symptoms often diagnosed as
Mental Health Disorders
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• Secondary symptoms are problems that come
about because of having post-traumatic reexperiencing and avoidance symptoms.
• Over time, secondary symptoms can become more
troubling and disabling than the original reexperiencing and avoidance symptoms.
• Associated symptoms are problems that don't
come directly from being overwhelmed with fear,
but happen because of other things that were
going on at the time of the trauma. For example: a
person who gets psychologically traumatized in a
car accident might also get physically injured and
then get depressed because he can't work or leave
the house.
These problems can be secondary
or associated trauma symptoms:
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• Depression: can happen when a person has
losses connected with the trauma situation or
when a person avoids other people and becomes
isolated.
• Despair and hopelessness: can happen when a
person is afraid that he or she will never feel
better again.
• Loss of important beliefs: can happen when a
traumatic event makes a person lose faith that
the world is a good and safe place.
• Aggressive behavior toward oneself or others:
can happen due to frustration over the inability
to control PTSD symptoms (feeling that PTSD
symptoms "run your life.
These problems can be secondary or
associated trauma symptoms, cont.
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• Self-blame, guilt, and shame: can happen when
PTSD symptoms make it hard to fulfill current
responsibilities.
• Social isolation: can happen because of social
withdrawal and a lack of trust in others. This
often leads to loss of support, friendship, and
intimacy, and grows fears and worries.
• Problems with identity: can happen when PTSD
symptoms change important things in a
person's life, like relationships or whether a
person can do your work well.
• Feeling permanently damaged: can happen
when trauma symptoms don't go away and a
person doesn't think they will get better.
These problems can be secondary or
associated trauma symptoms, cont.
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• Problems with self-esteem: can happen because
PTSD symptoms make it hard for a person to feel
good about him or herself. Sometimes, because
of things they did or didn't do at the time of
trauma, survivors feel that they are bad,
worthless, stupid, incompetent, evil, and so on.
• Physical health symptoms and problems: can
happen because of long periods of physical
agitation or arousal from anxiety.
• Alcohol and/or drug abuse: can happen when a
person wants to avoid bad feelings that come
with PTSD symptoms, or when other things that
happened at the time of trauma lead a person to
take drugs.
These problems can be secondary or
associated trauma symptoms, cont.
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• Problems in relationships with people: can
happen because people who have been through
traumas often have a hard time feeling close to
people or trusting people. This may be especially
likely to happen when the trauma was caused or
worsened by other people (as opposed to an
accident or natural disaster).
• Feeling detached or disconnected from others:
can happen when a person has difficulty in
feeling or expressing positive feelings. After
traumas, people can get wrapped up in their
problems or get numb and then stop putting
energy into their relationships with friends and
family.
These problems can be secondary or
associated trauma symptoms, cont.
• Getting into arguments and fights with people:
can happen because of the angry or aggressive
feelings that are common after a trauma. Also, a
person's constant avoidance of social situations
(such as family gatherings) may annoy family
members.
• Less interest or participation in things the person
used to like to do: can happen because of
depression following a trauma. Spending less
time doing fun things and being with people
means a person has less of a chance to feel good
and have pleasant interactions.
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Complex PTSD
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• Complex PTSD (sometimes called "Disorder of
Extreme Stress") is found among individuals who
have been exposed to prolonged traumatic
circumstances, especially during childhood, such
as childhood sexual abuse.
• Developmental research is revealing that many
brain and hormonal changes may occur as a result
of early, prolonged trauma, and contribute to
difficulties with memory, learning, and regulating
impulses and emotions.
• As adults, these individuals often are diagnosed
with depressive disorders, personality disorders or
dissociative disorders.
• Treatment often takes much longer, may progress
at a much slower rate, and requires a sensitive and
structured treatment program delivered by a
trauma specialist.
Ensuring Proper Treatment of
Trauma and PTSD
• Treatment for PTSD typically begins with a
detailed evaluation, and development of a
treatment plan that meets the unique needs of
the survivor.
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Generally, PTSD-specific-treatment is begun only
when the survivor is safely removed from a crisis
situation. Educating trauma survivors and their
families about how persons get PTSD, how PTSD
affects survivors and their loved ones, and other
problems that commonly come along with PTSD
symptoms. Understanding that PTSD is a medically
recognized anxiety disorder that occurs in normal
individuals under extremely stressful conditions is
essential for effective treatment.
Ensuring proper treatment of
trauma and PTSD, cont.
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• Exposure to the event via imagery allows the
survivor to re-experience the event in a safe,
controlled environment, while also carefully
examining their reactions and beliefs in relation
to that event.
• Examining and resolving strong feelings such as
anger, shame, or guilt, which are common among
survivors of trauma.
• Teaching the survivor to cope with post-traumatic
memories, reminders, reactions, and feelings
without becoming overwhelmed or emotionally
numb. Trauma memories usually do not go away
entirely as a result of therapy, but become
manageable with new coping skills.
Best Practice Approach to Treat
PTSD:
• Cognitive-behavioral therapy (CBT) involves
working with cognitions to change emotions,
thoughts, and behaviors.
• Exposure therapy is one form of CBT unique
to trauma treatment which uses careful,
repeated, detailed imagining of the trauma
(exposure) in a safe, controlled context, to
help the survivor face and gain control of the
fear and distress that was overwhelming in the
trauma.
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• In some cases, trauma memories or reminders can
be confronted all at once ("flooding").
Best practice approach to treat
PTSD, cont.
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• For other individuals or traumas it is preferable to
work gradually up to the most severe trauma by
using relaxation techniques and either starting
with less upsetting life stresses or by taking the
trauma one piece at a time ("desensitization").
• CBT for trauma includes learning skills for coping
with anxiety (such as breathing retraining or
biofeedback) and negative thoughts ("cognitive
restructuring"), managing anger, preparing for
stress reactions ("stress inoculation"), handling
future trauma symptoms, as well as addressing
urges to use alcohol or drugs when they occur
("relapse prevention"), and communicating and
relating effectively with people ("social skills" or
marital therapy).
Group Treatment
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Components of PTSD Treatment:
• Learning about trauma and PTSD.
• Talking to another person for support.
• Talking to your doctor about trauma and
PTSD.
• Practicing relaxation methods.
• Increasing positive distracting activities.
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• Taking prescribed medications to tackle
PTSD.
Components of PTSD Treatment:
• Negative Coping Actions
• Use of alcohol or drugs.
• Social isolation.
• Anger.
• Continuous Avoidance.
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How is PTSD treated in children and
adolescents?
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• Some children show a natural remission in PTSD
symptoms over a period of a few months, a
significant number of children continue to exhibit
symptoms for years if untreated.
• Few treatment studies have examined which
treatments are most effective for children and
adolescents.
• CBT for children generally includes the child
directly discussing the traumatic event (exposure),
anxiety management techniques such as relaxation
and assertiveness training, and correction of
inaccurate or distorted trauma related thoughts.
• CBT also involves challenging children's false
beliefs such as, "the world is totally unsafe." The
majority of studies have found that it is safe and
effective to use CBT for children with PTSD.
CBT is often accompanied by psychoeducation and parental involvement
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• Play therapy can be used to treat young children with
PTSD who are not able to deal with the trauma more
directly.
• Psychological first aid.
• Twelve Step approaches have been prescribed for
adolescents with substance abuse problems and PTSD.
• Eye Movement Desensitization and Reprocessing (EMDR)
combines cognitive therapy with directed eye
movements. While EMDR has been shown to be effective
in treating both children and adults with PTSD, studies
indicate that it is the cognitive intervention rather than
the eye movements that accounts for the change.
• Specialized interventions may be necessary for children
exhibiting particularly problematic behaviors or PTSD
symptoms. For example, a specialized intervention might
be required for inappropriate sexual behavior or extreme
behavioral problems.
Psycho-pharmacology (Basic overview
for non-medical professionals)
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• Medications can reduce the anxiety, depression,
and insomnia often experienced with PTSD, and
in some cases may help relieve the distress and
emotional numbness caused by trauma
memories.
• As of December 2001, two medications are
approved for treating PTSD by the U.S. Food and
Drug Administration (FDA), sertraline (Zoloft) and
paroxetine (Paxil), both selective serotonin
reuptake inhibitors (SSRIs). FDA approval is based
on multi-center double-blind studies.
• In addition to proven effectiveness, SSRIs are
considered the first-line medication treatment for
PTSD because their side effects are fewer and less
troubling.
Psycho-pharmacology, cont.
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• The Expert Consensus Guidelines also saw
promise in two comparatively new
antidepressants: nefazodone (Serzone) and
venlafaxine (Effexor) as second-line treatment if
SSRIs prove ineffective or are not well tolerated.
They have a more favorable side-effect profile
than the tricyclics.
• Tricyclic antidepressants (TCAs) could be
employed if the person has had a good response
to them in the past and they do not cause too
many side effects, or if the person has failed to
respond to or does not tolerate the SSRIs,
nefazodone or venlafaxine. Mood stabilizers may
be added to improve a partial response to an
antidepressant.
Psycho-pharmacology, cont.
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• Anti-anxiety medications (anxiolytics), including
benzodiazepines, are ideally used only briefly
and intermittently, if at all, to quell acute and
severe anxiety symptoms. While they reduce
anxiety rapidly, they also often induce sedation,
impaired coordination and the development of
physical dependency in those who use them for
more than a few weeks.
• Gabapentin (Neurontin) is sometimes used in the
place of benzodiazepines because it has similar
benefits and does not cause dependency.
• Buspirone (BuSpar) may be a helpful adjunctive
treatment for anxiety symptoms in people with
PTSD, although evidence for its effectiveness is
limited.
Psycho-pharmacology, cont.
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• Monoamine oxidase inhibitors (MAOIs) have also
been shown to be helpful in PTSD. However,
MAOIs are rarely used because of more frequent
side effects than found with SSRIs and because a
careful diet must be followed to prevent
dangerous increases in blood pressure.
• If a medication is well tolerated, most people will
continue to take it for 6 to 12 months if they
have acute PTSD (less than 3 months duration)
and for at least 12 and as long as 24 months for
chronic PTSD before trying to taper off the
medication.
• If PTSD symptoms return when medication is
being discontinued, the effective dose would be
resumed and usually continued for an even
longer time before discontinuation is tried again.