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Sorting through the Signs and Symptoms:
Understanding & Treating
Posttraumatic Stress Disorder
Jessica Holton, MSW, LCSW, LCAS
Holton, 2014 1
Learning Objectives
1. Participants will be able to compare the diagnostic criteria of PTSD from the DSM-IV-TR to the DSM-5.
2. Participants will understand the neurobiology of trauma.
3. Participants will apply effective treatment technique specific to PTSD.
Holton, 2014 2
Signs and Symptoms
Signs – Cues that can be witnessed by others (fidgeting, darting eye gaze, tearful, et cetera)
Symptoms – Subjective, self-reported, and typically cannot be witnessed (feeling anxious, feeling apprehensive, chronic pain)
Holton, 2014 3
Signs and Symptoms
Loss of interest
Difficulty concentrating
Irritability or anger out bursts
Sleep difficulties
Avoidance
Holton, 2014 4
Individuals Seek Treatment For:
Depression
Mood Swings
Anger
Substance Abuse
Relationship Issues
Concentration Struggles
Legal Issues
Sleep Difficulties
Chronic Pain Holton, 2014 5
Possible Disorders or Diagnoses
Attention-Deficit/Hyperactivity Disorder?
Major Depressive Disorder?
Generalized Anxiety Disorder?
Bipolar Disorder?
Schizoaffective Disorder?
Posttraumatic Stress Disorder?
Acute Stress Disorder?
Substance Induced __________?
Adjustment Disorder?
Holton, 2014 6
DSM-IV-TR
Posttraumatic Stress Disorder
Holton, 2014 7
Posttraumatic Stress Disorder
First and foremost:
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.
Holton, 2014 8
Posttraumatic Stress Disorder
If BOTH criteria in section A is met,
then one can proceed with the
exploring the PTSD diagnosis further.
Holton, 2014 9
Posttraumatic Stress Disorder
REEXPERIENCING:
B. The traumatic event is PERSISTENTLY REEXPERIENCED in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, and perceptions.
2. Recurrent distressing dreams of the event.
3. Acting or feeling as if the traumatic event were recurring.
Holton, 2014 10
Posttraumatic Stress Disorder
REEXPERIENCING (continued):
B. The traumatic event is PERSISTENTLY REEXPERIENCED in one (or more) of the following ways:
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.
Holton, 2014 11
Posttraumatic Stress Disorder
AVOIDANCE:
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:
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
Holton, 2014 12
Posttraumatic Stress Disorder
AVOIDANCE (continued):
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:
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (emotional expression)
7. Sense of a foreshortened future
Holton, 2014 13
Posttraumatic Stress Disorder
AROUSAL:
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response
Holton, 2014 14
Posttraumatic Stress Disorder
Duration:
E. Duration of the disturbance is more that one month (less than one month could be Acute Stress Disorder)
Disturbance In Functioning:
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify:
Acute – Durations of symptoms is less than three months
Chronic – Duration of symptoms is three months or more
With Delayed Onset – Onset of symptoms is at least six months after the stressor
Holton, 2014 15
Acute Stress Disorder
First and foremost, as with PTSD:
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.
Holton, 2014 16
Acute Stress Disorder
DISSOCIATIVE:
B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
1. A subjective sense of numbing, detachment, or absence of emotional responsiveness
2. A reduction in awareness of his or her surroundings (“being in a daze”)
3. Derealization
4. Depersonalization
5. Dissociative amnesia (inability to recall an important aspects of the trauma)
Holton, 2014 17
Acute Stress Disorder
REEXPERIENCED:
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 the reminders of the traumatic event.
AVOIDANCE:
D. Marked AVOIDANCE of stimuli that arouse recollections of the trauma (thoughts, feelings, conversations, activities, places, people, et cetera)
Holton, 2014 18
Acute Stress Disorder
AROUSAL:
E. Marked symptoms of anxiety or INCREASED AROUSAL (difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
DISTURBANCE
F. The DISTURBANCE caused clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs individual’s ability to pursue some necessary tasks, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
Holton, 2014 19
Acute Stress Disorder
DURATION:
G. The disturbance lasts from a MINIMUM of TWO DAYS and the MAXIMUM of FOUR WEEKS (ONE MONTH) of the traumatic event.
**If the signs and symptoms are present for one month or longer, the diagnosis transitions to PTSD
RULING OUT:
H. The disturbance is not due to the direct physiological effects of substance abuse or 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.
Holton, 2014 20
DSM-5
(effective Oct. 1, 2014)
Posttraumatic Stress Disorder
Holton, 2014 21
Posttraumatic Stress Disorder
• No longer listed under Anxiety Disorders.
• Separate section of Trauma- and Stressor-Related Disorders
• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
• Posttraumatic Stress Disorder
• Acute Stress Disorder
• Adjustment Disorders
• Other Specified Trauma- and Stressor-Related Disorder (not the same as Not Otherwise Specified)
• Stressor criterion is more explicit.
• Expansion of symptom clusters.
• Criterion different for children 6 years old and younger.
Holton, 2014 22
Posttraumatic Stress Disorder
The following criteria not applicable to children younger than 6 years old.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of traumatic event(s) (e.g., first responders; police officers repeatedly exposed to details of child abuse).
Note: Does not apply to exposure through electronic media, television, movies or pictures, unless exposure is work related.
Holton, 201 23
Posttraumatic Stress Disorder
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
3. Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Reactions may occur on a continuum.)
4. Intense prolonged psychological distress at the exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Holton, 201 24
Posttraumatic Stress Disorder
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with traumatic event(s).
Holton, 201 25
Posttraumatic Stress Disorder
D. Negative alteration in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined.”)
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g. fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participant in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Holton, 201 26
Posttraumatic Stress Disorder E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or now provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
Holton, 201 27
Posttraumatic Stress Disorder
F. Duration of the disturbance is more that one month (less than one month could be Acute Stress Disorder)
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
Holton, 2014 28
Posttraumatic Stress Disorder
Specify whether:
With dissociative symptoms
1. Depersonalization
2. Derealization
Specify if:
With delayed expression
Holton, 2014 29
Acute Stress Disorder
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of traumatic event(s) (e.g., first responders; police officers repeatedly exposed to details of child abuse).
Note: Does not apply to exposure through electronic media, television, movies or pictures, unless exposure is work related.
Holton, 201 30
Acute Stress Disorder
B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:
Intrusion Symptoms
Negative Mood
Dissociative Symptoms
Avoidance Symptoms
Arousal Symptoms
Holton, 201 31
Acute Stress Disorder
C. Duration of the disturbance is three days to one month after trauma exposure.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.
Holton, 2014 32
Neurobiology of Trauma
Holton, 2014 33
Our Brain…
Holton, 2014 34
Thought and Control Center
Emotions
Survival (Flight/Fight/Freeze)
The way the brain SHOULD allocate resources for optimal development and functioning:
Holton, 2014 35
EXAMPLES OF TRAUMATIC EVENTS
COMBAT / WAR ZONE
MOTOR VEHICLE ACCIDENT
EXPERIENCING ABUSE (PHYSICAL, SEXUAL, VERBAL, EMOTIONAL)
MEDICAL TRAUMA
WITNESSING OR EXPERIENCING DOMESTIC VIOLENCE
WITNESSING DEATH
NATURAL DISASTERS
VIOLENT LIVING ENVIRONMENT
Holton, 2014 36
Thought and
Control Center
Emotions
Survival (Fight/Flight/Freeze)
The way the brain allocates resources when traumatized:
Holton, 2014 37
Holton, 2014 38
Stress and Stress Responses
Holton, 2014 39
Emotional stress can affect you physically,
emotionally, spiritually, mentally and socially.
PHYSICAL
appetite changes
headaches
tension
fatigue
insomnia
weight change
colds
muscle aches
digestive upsets
pounding heart
accident prone
teeth grinding
rashes or skin problems
restlessness
foot-tapping
finger-drumming
increased alcohol, drug or tobacco use
Holton, 2014 40
STRESS RESPONSES
MENTAL
forgetful
dull senses
poor concentration
low productivity
negative attitude
EMOTIONAL
anxiety
frustration
the “blues”
mood swings
bad temper
nightmares
crying spells
irritability
“no one cares”
depression
nervous laugh
worrying
easily discouraged
little joy
Holton, 2014 41
STRESS RESPONSES SPIRITUAL
emptiness
loss of meaning
doubt
unforgiving
martyrdom
looking for magic
loss of direction
needing to “prove” self
Cynicism
apathy
Holton, 2014 42
STRESS RESPONSES SOCIAL
isolation
intolerance
loneliness
lashing out
hiding
clamming up
lowered sex drive
nagging
distrust
fewer contacts with friends
lack of intimacy
confusion
lethargy
whirling mind
no new ideas
boredom
spacing out
negative self-talk
using people
Holton, 2014 43
Coping Skills
Holton, 2014 44
Types of Coping
Action-based coping
Action-based coping involves actually dealing with a problem that is causing stress. Examples can include getting a second job in the face of financial difficulties, or studying to prepare for exams. Examples of action-based coping include planning, suppression of competing activities, confrontation, self-control, and restraint.
Holton, 2014 45
Types of Coping
Emotion-based coping
Emotion-based coping skills reduce the symptoms of stress without addressing the source of the stress. Sleeping or discussing the stress with a friend are all emotion-based coping strategies. Other examples include denial, rationalization, repression, wishful thinking, distraction, relaxation, and humor. There are both positive and negative coping methods.
Holton, 2014 46
Unhealthy Coping Skills
Harmful coping methods
Some coping methods are more like habits than skills, and can be harmful. Overused, they may actually worsen one's condition. Alcohol, cocaine, and other drugs may provide temporary escape from one's problems, but, with excess use, ultimately result in greater problems. Other less extreme cases involve skin biting, nail biting, and hair pulling.
Holton, 2014 47
Assessment and Rapport Building
Holton, 2014 48
Holton, 2014
49
PERSON-IN-ENVIORNMENT (PIE) APPROACH
It is essential to get the whole picturewhole picture, first handfirst hand, and consider various perceptions.
Individuals grow and change, thus understand that they are often at a different leveldifferent level (either better or worse) as their experiences change.
If coco--occurring diagnosis are presentoccurring diagnosis are present, realize that the conditions need to be addressed at the same timesame time!
Holton, 2014 50
UNDERLYING ISSUES & ADDICTION
Are their links between the addictionaddiction and mood symptoms?mood symptoms? Which occurred first?
Are there patterns of unhealthy behaviors, such as anger outburstsanger outbursts, turbulent turbulent relationships (codependency), minimizing relationships (codependency), minimizing issues (denial), control issues (external issues (denial), control issues (external locus of control), low selflocus of control), low self--esteemesteem, low selflow self--worth, etc?worth, etc?
It is necessary to understand It is necessary to understand
feelings and emotions.feelings and emotions. Holton, 2014 51
What triggers unhealthy coping skills?
How to cope with the triggers and cravings in a healthyhealthy way?
Methods to rere--traintrain the middle brain. It takes tools, time and practice to re-train that “survival centersurvival center” of the brain.
Establish and practice positivepositive, supportivesupportive and safesafe interactions to encourage replacing the dysfunctional behaviors to functional behaviors.
LivingLiving compared to SurvivingSurviving
Being a WitnessWitness rather than a VictimVictim! Holton, 2014 52
Georgi, J. M., 2004
Treatment Considerations
Holton, 2014 53
Scope of Practice
Clinicians who specialize in treating trauma
Clinicians who understand, and are able to work with, individuals with legal issues
Clinician who specialize in treating co-occurring disorders
PTSD and Substance Use
PTSD and Chronic Pain
PTSD, Generalized Anxiety Disorder, and Substance Use
Holton, 2014 54
TREATMENT MODALITIES
CBT- Cognitive Behavioral Therapy
TF-CBT – Trauma Focused – Cognitive Behavioral Therapy
Biofeedback & Neurofeedback
DBT – Dialectal Behavioral Therapy
CPT – Cognitive Processing Therapy
EMDR - Eye Movement Desensitization and Reprocessing
Holton, 2014 55
Trauma Focused – Cognitive Behavioral Therapy (TF-CBT)
Emotional Identification
Stress Management
Coping Skills
Though Distortions
Psychoeducation
Narrative or Letters
Safety and/or Boundaries
Evaluation Holton, 2014 56
Trauma Focused – Cognitive Behavioral Therapy
COGNITIVE TRIANGLE
HOW IT’S ALL RELATED . . .
Something Happens
Thoughts
Feelings Behaviors
Holton, 2014 57
Suggested Models, Methods, & Techniques
Holton, 2014 58
Daily Gratitude Journal
• Successes / Positives
• Challenges / Negatives
• What are you grateful for?
Holton, 2014 59
Deep Breathing
Breathe in and out from your diaphragm (not chest).
Breathe in for four (4) seconds
Breathe out for four(4) seconds
This is one (1) cycle
Complete at least six (6) to twelve (12) cycles
This changes the blood flow from your chest
(heart and lungs = preparing for Survival - Fight and Flight)
to your extremities (arms and hands), which cues the brain that it is no longer in Survival - Fight or Flight - mode.
Holton, 2014 60
Activities that Engage Frontal Lobe
(Re-allocate energy from the Limbic System, to Frontal Lobe)
Counting
Adding
Subtracting
Organizing
Alphabetizing
Word Searches
Jigsaw Puzzles
Balancing on one leg
Hopping on one leg
*Mindfulness
*Grounding
This type of action based coping pulls energy to the frontal lobe (thought and control center) and away from the Limbic System (intricate Fight and
Flight/Survival Center). Holton, 2014 61
Biofeedback Mantra
“My mind is quite quiet. My hands are warm and heavy.”
Repeat the above mantra while visualizing your hands glowing bright. Feel your hands warming up and being weighted down.
This changes the blood flow from your chest (heart and lungs = Fight and Flight/Survival) to your extremities (arms and hands), which cues the brain that it is no longer in Fight or Flight/Survival.
Can be used as preventative or action based coping. Data has indicated that this exercise assists in preventing:
Migraines
High Blood Pressure
Anxiety
Headaches
TMJ Holton, 2014 62
Anxiety Management Mantras
“Fear is not real. Danger is real.”
“Anxiety is my fear, linked to the future, linked to my imagination.”
“What are the facts that counter is fear/anxiety?”
“Focusing on anxious thoughts is similar to wishing for the very thing that I fear.”
F.E.A.R. = Forget Everything and Run;
False Evidence Appearing Real
OR
Face Everything and Recover Holton, 2014 63
Danger Sequence
Am I in danger? Fear is not real. Danger is. 95-99% of the time, I am not in danger.
• The answer is NO
Are past traumas (real saber tooth tigers) being triggered?
• If yes, counter with facts: Age, location, year, individuals involved, actions, ect.
• If no, move to #3.
Are past negative life (mutated saber tooth tigers) events being triggered?
• If yes, counter with facts: Age, location, year, individuals involved, actions, ect.
• If no, move to #4
What are the specific stressors (hologram saber tooth tigers)?
What are the tangible solutions (not anxiety or fear based)
Follow sequence, without adaptions. Repeat often. Practice on small stressors in order to build “muscle memory” for the larger stressors, trauma triggers, and/or crisis that might occur.
Holton, 2014 64
Grieving Process:
1) Shock/Denial
2) Anger
3) Bargaining
4) Depression
5) Acceptance Marrone, 1997
Holton, 2014 65
Holton, 2014 66
Holton, 2014 67
Revised Healing Process:
1) Denial
2) Bargaining
3) Anger (Projection)
4) Depression (Blah, Guilt)
5) Acceptance (Sobriety)
Holton, 2014 68
“Stages of Change” “Stages of Change” -- It’s A It’s A ProcessProcess
Precontemplation (Denial): Not thinking of quitting Feel that things are fine Do not see a problem
Contemplation(Bargaining): Thinking of quitting Thinking of how others have been affected Try small changes
Preparation (Bargaining & Anger): Have a plan to quit May have “cut down” on use Can see the positives of being clean
Action(Anger & Depression): Have quit using Avoiding triggers Ask others for help
Maintenance (Acceptance): Have not used in a long time Accept self and sobriety Help others who still use
Velasquez, Maurer, Crouch, & DiClemente.,2001
Holton, 2014 69
Smartphone Apps
• PTSD Coach
• Breath2Relax
• T2 Mood Tracker
Holton, 2014 70
SUCCESS
To laugh often and much; to win the respect of
intelligent people and the affection of children; to earn
the appreciation of honest critics and endure the
betrayal of false friends; to appreciate beauty; to find the
best in others; to leave the world a bit better, whether by
a healthy child, a garden patch, or a redeemed social
condition; to know even one life has breathed easier
because you lived; this is to have succeeded.
--attributed to Ralph Waldo Emerson
(1803-1882)
Holton, 2014 71
THOUGHTS, COMMENTS
OR QUESTIONS?
Holton, 2014 72
For more information, contact:
Jessica Holton
MSW, LCSW, LCAS
Jessica Holton, PLLC
http://www.jessicaholton.com
3491 Evans Street
Suite A
Greenville, NC 27834
252-987-3039 [email protected]
Holton, 2014 73
References American Psychiatric Association (2013). Diagnostic and statistical manual
of mental disorders (5th ed.). : Author. Arlington, VA: Author.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author.
Georgi, J. M. (2004). Treatment issues for dual diagnosis: Post traumatic stress disorder and substance abuse. Presentation sponsored by Eastern AHEC. Greenville, NC.
Saeed, S. (2013). From DSM-IV-TR to DSM—5: What specifically is changing? Presentation sponsored by Eastern AHEC. Greenville, NC.
Sidbury, L. & Owens, C. (2005). Critical incident stress and emergency response. Presentation sponsored by Pitt Community College. Greenville, NC.
Valasquez, M.M., Gaylyn, G.M., Crouch, C. & DiClemente, C.C. (2001). Group treatment for substance abuse: A stages-of-change therapy manual. New York: The Guilford Press.
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