POST-TRAUMATIC STRESS DISORDER: A COMPREHENSIVE OVERVIEW FOR MENTAL HEALTH CLINICIANS

by Michelle Lind, LCSW, DHSc, LIMFT, M-RAS


Dr. Michelle Lind is a licensed Social Worker with several years of experience providing clinical services as Social Worker and Sexual Assault Specialist to military personnel and their families. She is currently working as a special court appointed advocate and is on the faculty at Axia University of the University of Phoenix.


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OBJECTIVES

The objective of this course is to provide the mental health clinician with a comprehensive introductory overview of Post-traumatic Stress Disorder and its treatment. When the trainee completes this course, he/she will:

1. Comprehend the causes and symptoms of PTSD
2. Understand the manifestations of PTSD in children
3. Identify the most commonly utilized treatment approaches for responding to PTSD
4. Comprehend the uses of Critical Incident Stress Management as a preventive approach for PTSD
5. Understand the uses and limitations for psychotropic medication approaches to PTSD
6. Comprehend common barrier to treatment for PTSD



This course is primarily designed for clinicians in the early or middle stages of their career, or for more advanced clinicians reviewing basic concepts in this area.

Course length:

3 contact hours: Core clinical

COURSE INDEX

Section I: INTRODUCTION
Section II: PTSD Facts and Statistics
Section III: Causes and Symptoms of PTSD
Section IV: PTSD in Children
Section V: Treatments for PTSD
Section VI: The Preventive Approach to PTSD
Section VII: Barriers to Treatment
Conclusion
References and Test

Section I: INTRODUCTION

Post-traumatic Stress Disorder, commonly abbreviated as PTSD, is a clinical syndrome that was formally recognized as a psychiatric diagnosis in1980. (American Psychiatric Association, 2005) PTSD usually occurs as a reaction to: 1) participation in; or 2) exposure to a violent, dangerous or otherwise traumatizing event that threatens one’s sense of safety or well being.

As a syndrome or disorder, PTSD typically consists of a constellation of different symptoms which develop as a response to exposure to the traumatic event. Symptoms include but are not limited too: increased arousal and heightened vigilance, anxiety producing recollection and re-experiencing of the traumatic event, and a number of associated affective and physiological after-effects, such as psychological numbing, confusion, difficulties sleeping, and difficulties sleeping, concentrating, and sustaining control over fear, anxiety and other feelings.

PTSD is typically associated with combat veterans; however, it can and does afflict many other people exposed to different kinds of trauma. Like other mental illness, PTSD has no boundaries; it does not discriminate based upon gender, education level, race, or socio-economic status.

There is some debate on whether the leading cause of PTSD is exposure to combat, sexual assault, or motor vehicle accidents, but because of the sheer number of the driving population, serious motor vehicle accidents may be the leading contributor, while combat-related PTSD receives the most attention.

Regardless of the leading cause, more attention is being brought to this syndrome than ever before. As veterans speak out to the media about the symptoms associated with this syndrome, PTSD has been gaining national coverage. As a result, more and more clinicians are now accepting the diagnosis of PTSD, and more and more people are seeking treatment.

It is important for today's clinicians to understand that this condition is not unique to veterans. Other people, including children, can develop this disorder as a result of a traumatic event or experience. Clients seeking help for the first time as adults often have a history of acute or ongoing traumatic experiences that served as the point of origin for their later emotional and psychological problems.

Adult Children of Alcoholics, sexual abuse survivors, survivors of physical and emotional abuse, and survivors of domestic abuse are all categories of people whose problems have their roots in traumatic experience and whose symptoms have some overlap with symptoms of PTSD. While the diagnoses for these clients may not meet the diagnostic criteria for PTSD, a clear and solid understanding of the mechanisms through which traumatic experience evolves into emotional, psychological, physiological and behavioral problems should be an integral part of each clinician’s foundation of understanding.

Additionally, treatment approaches for these kinds of problems will incorporate some of the principles of treatment for PTSD. As will be demonstrated in the section that examines the various approaches for treatment of PTSD, there will be many components of treatment that make sense for intervening with clients who are survivors of family chaos, violence and abuse.

One other group of patients warrants special mention here. Borderline Personality Disorder (BPD) appears to have a high degree of correlation with PTSD. One study of veterans with combat-related PTSD seeking treatment found that 76% of them also had a diagnosis of BPD. (Southwick, 1993) Likewise, another study found that approximately 56% of individuals with BPD also have a diagnosis of PTSD. (Zanarini, 1998)

Why are these two disorders so inter-related? Some current theories posit that BPD is primarily a symptom of ongoing and persistent reactions to stress and trauma. The trauma creates a state of relatively permanent hyper-arousal and hyper-vigilance that leads to personal disorganization and over-reactivity to emotional stimuli: the primary characteristics of BPD.

This in turn leads to a self-propagating cycle where the impulsive behaviors and difficulties managing emotion seen among people with BPD may also place a person at greater risk for experiencing further trauma, as they engage in impulsive behaviors that can lead to accidents, assaults, and the fraying of social supports. This same self-propagating process appears quite frequently in patients who suffer from chronic symptoms of PTSD.

There are two well-supported treatments for BPD, Dr. Marsha Linehan's Dialectical Behavior Therapy (DBT) and Drs. Anthony Bateman and Peter Fonagy's Mentalization-Based Treatment (MBT). Some of the skills taught in these treatments (for example, emotion regulation, emotional awareness (mindfulness), interpersonal effectiveness skills) have been incorporated into some of the research based approaches to treating PTSD. (Linehan, 1993)

It is likely that additional research will determine the extent to which BPD and PTSD overlap, and where distinctions can be drawn between the two diagnostic categories and the treatment for each. However, conscientious clinicians should have some familiarity with both areas of study, as well as some understanding of the key treatment approaches used in DBT and MBT.

Currently there is a sizeable shortage of healthcare providers with expertise in treating trauma-related mental disorders, and the need for trained professionals is growing. (Barnes, 2008) To meet the growing demand for competent care, clinicians must be equipped or trained to help those who have experienced severe trauma and who have perhaps developed PTSD.

Clinicians work in a variety of practice settings such as hospitals, private practices, schools, and other clinical arenas. As such, clinicians are often confronted with a multitude of presenting symptoms from the client. Although, clinicians do not necessarily need to become specialists or experts in the treatment of PTSD, they should nevertheless have a sufficient understanding of PTSD to diagnose it appropriately, provide routine support to stabilize it, and know how to make the appropriate referral.

Therefore, the clinician should have a store of knowledge to draw upon to complement what is presented by the client or documented in the patient's medical record. Additionally, clinicians should have known resources – clinicians who specialize in PTSD or response to acute trauma - to which they can refer a client who presents with PTSD.

This course will serve as a starting point for clinicians to understand these mechanisms, as well as the treatment approaches that are generally considered effective in responding to symptoms of PTSD.

As a starting point for this course, we will present here a summary sheet that encapsulates much of the information concerning Posstraumatic Stress Disorder, and the associated diagnosis of Acute Stress Disorder. 

                      Posttraumatic Stress Disorder Summary Page

DSM-5 Code:       F43.10 Posttraumatic Stress Disorder

Common Specifiers:
• With dissociative symptoms
1. Depersonalization
2. Derealization

Etiology of Posttraumatic Stress Disorder: This disorder is created when a person is exposed to a trauma creating event(s) or other stressor(s) involving death, serious injury, or physical attack or violation, or the threat of these experiences, to one’s own self or another nearby person, whereby the experience exceeds that person’s adaptive capacity for processing the event, coping with the event, and/or integrating the event into a cohesive sense of the world as a safe and secure enough place. Signs and symptoms of PTSD may occur shortly after the experience of traumatic event, or may appear weeks or months after the traumatic event has occurred. The level of trauma and exposure needed to create Posttraumatic Stress Disorder varies from individual to individual, and factors that increase the risk of developing Acute Stress Disorder include genetically and temperamentally driven sensitivity to trauma effects, prior history of traumatic experiences, deficiencies in early childhood bonding experiences, the presence of other kinds of mental disorder, and/or deficits in the availability of emotional support resources, such as close relationships.

Prevalence: Prevalence rates for the general public are not clear, but it is estimated that between 5 and 20% of people exposed to a traumatic event will go on to develop Acute Stress Disorder.

Clinical Manifestations: People with Acute Stress Disorder will present with a variety of symptoms along several different dimensions: 1) Intrusive Symptoms, such as intrusive memories of the event, or distressing dreams, or dissociative reactions, the most common of which are flashbacks; 2) Avoidance symptoms, such as efforts to avoid memories of the event, reminders of the event, or sensory cues that activate memories of the event (sight, sound, smell); Negative alterations in cognition and mood, that may include inability to remember aspects of the experience, negative self-beliefs, distortions about the causes of the events, negative mood states and increased difficulties in experiencing positive mood states, and feelings of estrangement or detachment from other people and important life events; 3) Dissociative Symptoms, such as depersonalization, derealization, or an inability to remember the event due to dissociative amnesia; 3) An increase in arousal probless, such as hypervigilance and enhanced startle response, concentration problems and/or sleep disturbance. For this diagnosis to be applied, the patient must experience clinically significant distress and/or disruptions to major life areas, such as work or relationships, and must have been exposed to experiences that create a threat to life, physical safety, or violence to self or close others. Experiencing repeated or extreme exposure to aversive details of traumatic events, such as by safety personnel and first responders, may also create circumstances in which PTSD is created through vicarious exposure.

Best Practices Diagnostic Approaches: An accurate diagnosis of Posttraumatic Stress disorder will involve gathering a thorough history of the client and his/her exposure to the trauma producing event(s), and an inventory of the post-event signs and symptoms, including timelines for the development of those signs and symptoms. The history taking should include an exploration of prior historical events, such as prior trauma, family dysfunction, and/or other disorders and life circumstances that may be predisposing factors for the development of Posttraumatic Stress Disorder. Signs and symptoms must be present more than 4 weeks after exposure to the trauma causing event(s) for this diagnosis to be applied.

Best Practices Treatment Approaches: Best practices treatment approaches for Posttraumatic Stress Disorder should include several integrated components through a six-stage process, according to PTSD specialist Sherri Falsetti: 1) Psychoeducation phase, with thorough education on PTSD, trauma and co-morbid problems; 2) Coping skills development phase, where important coping skills - like anxiety control - are taught; 3) Imaginal exposure phase, where patients are directed to begin reprocessing of the trauma through indirect exposure by imagination; 4) Cognitive stage, where CBT approaches are used to begin cognitive reprocessing of the traumatic event; 5) Behavioral task scheduling phase, where systematic desensitization to the trauma producing events is outlined then pursued in a step by step manner with support and further cognitive reprocessing, including the possible use of Multiple Channel Exposure Therapy; 6) Relapse prevention phase, where triggers are uncovered and a plan is created to avoid then address panic inducing cues; 7) Evaluation phase, where assessment of additional treatment needs is conducted and additional treatment strategies are put into place. Additional treatment may include such approaches as EMDR, Acceptance and Commitment Therapy, supportive group therapy, relationship and family therapy, and Stress Inoculation Therapy.

Other Conditions to Rule Out: This disorder must be distinguished from an adjustment disorder, whose signs and symptoms may include the development of anxiety, depression, and/or behavior/conduct changes, but whose symptoms do not include dissociative symptoms and/or as high a degree of arousal, avoidance, or intrusive symptoms. This disorder must also be distinguished from Dissociative Disorders where the presence of dissociative symptoms generates additional distress that may lead to Negative Mood as exhibited by the presence of anxiety and depression. Persons with extreme and persistent PTSD may present with signs and symptoms that are seen in Borderline Personality Disorder. Clients who abuse certain substances or medications that are CNS stimulants and/or hallucinogens may also appear with signs and symptoms that can appear similar to Acute Stress Disorder.

Comments: This disorder may legitimately be diagnosed by Master’s level mental health clinicians, but considerable care should be taken to gather sufficient history to ensure the ruling out of the disorders that may be mistaken for Posttraumatic Stress Disorder. There is a considerable degree of overlap between the presentation of Acute Stress Disorder and Posttraumatic Stress Disorder, the key distinction being the time frames in which the signs and symptoms occur: before a month has elapsed since the development of signs and symptoms, a diagnosis of Acute Stress Disorder should be utilized; after a month has elapsed and symptoms persist, then Posttraumatic Stress Disorder should be utilized as a diagnosis. The degree of personality disorganization that may occur as a secondary result of persistent and ongoing PTSD may lead to the development of signa and symptoms of Borderline Personality Disorder. The application of well-constructed cognitive-behavioral treatment approaches “have yielded the most consistently positive results in terms of preventing subsequent posttraumatic psychopathology”, according to the Veterans Administration.


                      Acute Stress Disorder Summary Page

DSM-5 Code:       F43.0 Acute Stress Disorder

Common Specifiers:
• None

Etiology of Acute Stress Disorder: This disorder is created when a person is exposed to a trauma creating event(s) or other stressor(s) involving death, serious injury, or physical attack or violation, or the threat of these experiences, to one’s own self or another nearby person, whereby the experience exceeds that person’s adaptive capacity for processing the event, coping with the event, and/or integrating the event into a cohesive sense of the world as a safe and secure enough place. It is believed that the more direct the exposure to the trauma creating event, the more likely the person is to develop signs and symptoms indicating Acute Stress Disorder. The level of trauma and exposure needed to create Acute Stress Disorder varies from individual to individual, and factors that increase the risk of developing Acute Stress Disorder include genetically and temperamentally driven sensitivity to trauma effects, prior history of traumatic experiences, deficiencies in early childhood bonding experiences, the presence of other kinds of mental disorder, and/or deficits in the availability of emotional support resources, such as close relationships.

Prevalence: Prevalence rates for the general public are not clear, but it is estimated that between 5 and 20% of people exposed to a traumatic event will go on to develop Acute Stress Disorder.

Clinical Manifestations: People with Acute Stress Disorder will present with a variety of symptoms along five different dimensions: 1) Intrusive Symptoms, such as intrusive memories of the event, or distressing dreams; 2) Negative Mood; 3) Dissociative Symptoms, such as depersonalization, derealization, or an inability to remember the event due to dissociative amnesia; 4) Avoidance Symptoms, such as efforts to avoid memories of the event or reminders of the event; 5) Arousal Symptoms, such as hypervigilance and enhanced startle response, or sleep disturbance. For this diagnosis to be applied, the patient must experience clinically significant distress and/or disruptions to major life areas, such as work or relationships.

Best Practices Diagnostic Approaches: An accurate diagnosis of Acute Stress disorder will involve gathering a thorough history of the client and his/her exposure to the trauma producing event, and an inventory of the post-event signs and symptoms, including timelines for the development of those signs and symptoms. The history taking should include an exploration of prior historical events, such as prior trauma, family dysfunction, and/or other disorders and life circumstances that may be predisposing factors for the development of Acute Stress Disorder. Signs and symptoms must persist for at least 3 days for this diagnosis to be applied. Persistence of signs and symptoms beyond one month indicate that the disorder has moved from Acute Stress Disorder to Posttraumatic Stress Disorder.

Best Practices Treatment Approaches: Treatment approaches for Acute Stress Disorder include supportive individual or group therapy, with Cognitive Behavioral Therapy as a central component, as well as possible use of elements of exposure therapy combined with anxiety management techniques. Some research supports the use of Critical Incident Stress Management approaches as a preventive measure for groups of persons who experience the same trauma-causing event, where the traumatic event is processed in a structured group setting within 24 hours from the event occurrence. However, there have been some concerns raised about the efficacy of this approach, particularly for some participants who may be susceptible to further traumatization from focusing on the traumatic events.

Other Conditions to Rule Out: This disorder must be distinguished from an adjustment disorder, whose signs and symptoms may include the development of anxiety, depression, and/or behavior/conduct changes, but whose symptoms do not include dissociative symptoms and/or as high a degree of arousal, avoidance, or intrusive symptoms. This disorder must also be distinguished from Dissociative Disorders where the presence of dissociative symptoms generates additional distress that may lead to Negative Mood as exhibited by the presence of anxiety and depression. Clients who abuse certain substances or medications that are CNS stimulants and/or hallucinogens may also appear with signs and symptoms that can appear similar to Acute Stress Disorder.

Comments: This disorder may legitimately be diagnosed by Master’s level mental health clinicians, but considerable care should be taken to gather sufficient history to ensure the ruling out of the disorders that may be mistaken for Acute Stress Disorder. There is a considerable degree of overlap between the presentation of Acute Stress Disorder and Posttraumatic Stress Disorder, the key distinction being the time frames in which the signs and symptoms occur: before a month has elapsed since the development of signs and symptoms, a diagnosis of Acute Stress Disorder should be utilized; after a month has elapsed and symptoms persist, then Posttraumatic Stress Disorder should be utilized as a diagnosis. Additionally, ASD is more likely to involve feelings of depersonalization and derealization, according to the Veterann Administration’s National Center for TSD. Acute Stress Disorder does not inevitably lead to the development of Posttraumatic Stress Disorder, but research does indicate that ASD is predictive of the later development of PTSD to a substantial degree (Up to 78-82% in some studies). The application of well-constructed cognitive-behavioral treatment approaches “have yielded the most consistently positive results in terms of preventing subsequent posttraumatic psychopathology”, according to the Veterans Administration’s National Center for PTSD.

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