Ptsd: Alternatives for a better CHILD FOCUSED DIAGNOSIS?
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Transcript Ptsd: Alternatives for a better CHILD FOCUSED DIAGNOSIS?
Creating Connections to Shining Stars
Virginia Beach 17 July 2012
Jane C. Probst, MSW
Rappahannock Rapidan Community Services
Child & Family Clinical Services
[email protected]
Overview
Expanding Perceptions of Trauma
Childhood Trauma: Early Lessons Last a Lifetime
Diagnosing Childhood Trauma: DSM IV Criteria Existing Diagnoses
Trauma Researcher’s DSM V Proposals - Thinking Differently
DSM V Considered Diagnoses Changes – May 2013
Why Diagnoses Matter
Adverse Childhood Experiences Study (ACE)
ACE Adult Findings
ACE Co-Morbid Groups
Childhood into Adulthood Outcomes
Find Your ACE Score - PDF Score Sheet
Why Diagnoses Don’t Matter
Considering Trauma Treatment
References & Recommended Readings
Questions & Comments
Expanding Perceptions of Trauma
Natural Environment Traumas
Hurricanes, Earthquakes, Volcanoes, Floods, Fires - Random
Transportation Traumas
Vehicular Accidents: Land, Sea, Air - Random
Community Violence
Terrorist Attacks - Random
War, Ethnic & Cultural Discrimination – Time and place specific
Personal Violence
Stranger Danger, Assaults, Robbery, Sexual Assault/Rape – Random
Interpersonal Violence
Domestic Violence, Partner Abuse, Intimate Partner Violence
Occurs within the context of a relationship and is time-relative
Attachment Trauma and Early Childhood Trauma
Age of onset of trauma & trauma symptoms are inversely correlated
The younger the age of onset, the more complex the cascade of symptoms
Actually, on a cellular level, I’m very busy…
Infants are born with their fully developed & largest sensory organ – skin!
And ready to receive the initial stimulus to begin building neural connections.
Childhood Traumas: Early Lessons
What is Attachment and Attachment Trauma?
Secure or Insecure Attachment, Internal Working Model
Mother/primary caregiver is infant’s whole world
Reciprocal & symbiotic self-regulate emotions & return to homeostasis
Infants 1st job is to regulate body temperature and functions at birth
AT is chronic, accumulative, and compromises learning
“Inversely related to the age of onset of first trauma, such that those with early life trauma
are more likely to manifest” and accumulate symptoms throughout the lifespan. (van der
Kolk et al., 2005)
Natural trauma survival response options in “limbic animals”
Fight: infant has no physical power over abuser
Flight: source of safety is source of abuse/neglect place child in a double bind
Freeze – only option available to infants & children
Restricted brain development & integration in “freeze” state; flooding & restriction of
hormones
Lesson learned to numb – set up for later maladaptive coping
Pronking – exhilarated leaping into the air when contact with predator avoided
Defensive mechanism, warning to others of danger, exhilaration at survival
Polyvagal Theory 10th cranial nerve: evolution of Sympathetic & Parasympathetic
NS (Porges, 2011)
Emotional & physiological regulation synchronized with internal organ regulation
Bidirectional signals: 80% afferent (incoming) 20% efferent (outgoing).
Childhood Traumas: Early Lessons
Birth to 18 m. predominate right hemisphere development
Implicitly learned recognition: facial features, tone of voice,
incidental environmental cues
Incidental verbal/non verbal cues to the safety/danger from
caregivers & environment
Earliest implicit memories form outside awareness and become
hard-wired
Mirror neurons reciprocate all emotions, not just 6 we’re born with
Teaches emotion and self-regulation simultaneoulsy
Neurons that fire together, wire together (Hebbs, 1949)
The initial seeds of sympathy and empathy
Facial expressions, tone of voice, heart and breath rates model
regulation or dysregulation
Diagnosing Childhood Trauma
PTSD: Anxiety Disorder w/Discrete Event – Not a Child Focused Dx
DSM-V change PTSD to Trauma & Stressor Related Disorders – child focused
Ignores accumulative layers of chronic trauma, abuse & neglect
Disorder Extreme Stress Not Otherwise Specified - DESNOS
Captures complex trauma symptomatology
Not recognized by APA as a diagnosis, however clinicians use it as specifier
Reactive Attachment Disorder
Does not consider trauma outside of attachment with caregivers
Many professionals consider it an inaccurate diagnosis > 8 y.o.
Multiple Co-Morbid I, II, III Dx
Diagnostic behaviors are very disorganized & dysregulated; diagnoses difficult
ADHD, Bipolar, Conduct Disorder, ODD, Intermittent Explosive Disorder
Accurate assessments for early interventions
Critical learning periods are interrupted/disrupted/mitigated
Cascading impairments are accumulative and undeterminable
Restricts neural development, accelerates pruning
Researcher’s DSM V Proposals
Developmental Trauma Disorder (van der Kolk, 2005)
Comprehensive criteria targeting children
Under consideration by APA for DSM V
Field trials ongoing ; criteria info at www.traumacenter.org
Disorders of Extreme Stress NOS – DESNOS
Not accepted by APA but used as a ‘qualifier”
Can be Co-Morbid with PTSD Diagnosis
Different criteria from PTSD
PTSD - Organized Attachment (Classen et al., 2006) Rejected
Caregiver is not the abuser, however, caregiver is not protective
Poverty, DV, substance abuse, chronic A & N by others
Invisible, Parentified, Secretive
Hiding in plain sight
PTSD - Disorganized Attachment (Classen et al., 2006) Rejected
Caregiver is the abuser
Significant affect dysregulation
Narrow window of tolerance
Approach-avoidant behaviors: caregiver is abuser
DSM-V APA Considered Diagnoses
Trauma & Stressor Related Disorders: All Ages
Reactive Attachment Disorder, child is > 9 months
A & N by caregivers, incidental social cues of contempt & disregard
Disinhibited Social Engagement Disorder > 9 months
Multiple caregivers, indicative of children in chronic foster care
PTSD in Preschool Children < 6 years old
Acute Stress Disorder (no age limiting criteria)
Adjustment Disorders
Current subcategories with additions (PTSD/ASD symptoms)
Other Specified Trauma/Stressor Related Disorder
Unspecified Trauma/Stressor Related Disorder
No criteria determined at this time for either of the above
Developmental Trauma Disorder (van der Kolk, 2005)
For diagnoses & criteria info: www.dsm5.org
Why Diagnoses Matter
ATTACHMENT & ATTACHMENT TRAUMA HAPPEN AT CELLULAR LEVEL
Implicit memory begins in utero and is hard-wired
Inability of integrated narrative ability – left & right brain integration
Restricts critical periods of brain structure development & myelination
Stress hormones (cortisol, adrenalin, norepinephrine) flood brain/body
Body/brain develop with a baseline of stress hormones
Baseline lasts a lifetime without intervention.
Body regulation through CNS is infant’s main job from birth
Identify Dx for prevention, intervention, and treatment
Formulation & Implementation of Ethical MH Policies for Children
Attachment Styles are Generational (Hesse, 1999)
75% correlation attachment styles between generations (Schore, 2000)
Intervention reduces generational cycles of chronic abuse
USDHHS (2002) – identified 870,000 abused/neglected children in US
83.3% abused by primary caregiver
Infants to age 3 with highest rates of victimization and death
Research for evidence based treatments
All Axes considered for holistic functioning
Mental health: neurobiologically, physiologically, and medically necessary for survival
Attachment Theory - Darwin meets Freud!
ACE Longitudinal Study
1998 Kaiser Permanente & CDC
Adverse Childhood Experiences – ACE (n=13,494)
Identified 7 categories of abuse (self-reporting)
Substance abusing family member – 25.6%
Sexual abuse – 22%
Mental illness of caregiver – 18.8%
Violence against the mother – 12.5%
Psychological Abuse -11.1%
Physical Abuse - 10.8%
Family member incarcerated – 3.4%
Poverty & economic risk factors not considered
In depth outcome details: www.acestudy.org
ACE Adult Findings
Substance Abuse family member exposed to other category
(N=2064)
Mental illness of caregiver – 34%
Sexual Abuse – 34%
Violence against the mother – 29%
Psychological Abuse – 22%
Physical Abuse – 19%
Family member incarcerated – 8%
Violence against mother exposure other category (N=1010)
Substance abusing family member 59%
Sexual Abuse – 41%
Mental illness of caregiver – 38%
Psychological Abuse – 34%
Physical Abuse – 31%
Family member incarcerated – 10%
Witnessed assault with knife or gun – 3%
(Felitti et al., 1998)
Groups ≥ 4 of 7 Self-Report
Any combination of 4 or more groups:
Depression for 2 weeks in past year – 50.7%
Illicit drug Use – 28.4%
No leisure time/activity – 26.6%
Suicide attempts – 18.3 %
Smoking - 16.5%
Self identified alcoholic – 16.1%
Obesity - 12%
≥ 50 Sexual partners – 6.8%
STI’s – 6.8%
Childhood to Adulthood Health Outcomes
ACE Adult Health Outcomes Studied & Published:
Chronic Disease: Lung Cancer, Heart Disease, Autoimmune
Health Risks: Alcohol & Drug Abuse, Obesity, Smoking
Mental Health: Depression, Suicidality, Work Absenteeism
Victimization & Perpetration: Intimate Partner Violence
Sexual Behavior: Fetal Death, Teen Pregnancy, STD’s
Autobiographical Memory Disturbances
Impaired implicit and narrative memory
Special Populations Studies
Child Sexual Abuse Victims, Children of Alcoholics, War Refugees
www.cdc.gov/ace/outcomes.htm
Strong Correlations Between Attachment Trauma & PD
75% of BPD are women (DSM-IV-TR, 2000) w/history of multiple AT
Insecure attachment risk factor for PTSD severity in veterans
(Renaud, 2008)
Finding Your ACE Score
092406RA4CR
While you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household often or very often…
Swear at you, insult you, put you down, or humiliate you? or
Act in a way that made you afraid that you might be physically hurt?
Yes No If yes enter 1 ________
2. Did a parent or other adult in the household often or very often…
Push, grab, slap, or throw something at you? or
Ever hit you so hard that you had marks or were injured?
Yes No If yes enter 1 ________
3. Did an adult or person at least 5 years older than you ever…
Touch or fondle you or have you touch their body in a sexual way? or
Attempt or actually have oral, anal, or vaginal intercourse with you?
Yes No If yes enter 1 ________
4. Did you often or very often feel that …
No one in your family loved you or thought you were important or special? or
Your family didn’t look out for each other, feel close to each other, or support each other?
Yes No If yes enter 1 ________
5. Did you often or very often feel that …
You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or
Your parents were too drunk or high to take care of you or take you to the doctor if you
needed it?
Yes No If yes enter 1 ________
Finding Your ACE Score
6. Were your parents ever separated or divorced?
Yes No If yes enter 1 ________
7. Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? Or
Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?
Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
Yes No If yes enter 1 ________
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes No If yes enter 1 ________
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
Yes No If yes enter 1 ________
10. Did a household member go to prison?
Yes No If yes enter 1 _______
Now add up your “Yes” answers: _______ This is your ACE Score.
Higher the score, higher the risk consequences of Adverse Childhood Event
(Felliti & Anda, 1998)
For ACE Score diagnostic tool in Spanish, French, Icelandic, Norwegian, & Swedish
http://www.acestudy.org/yahoo_site_admin/assets/docs/ACE_Calculator-English.127143712.pdf
1st
Why
Diagnoses
Don’t
Matter
Rule - DO NO HARM
Constellation of Symptoms = Constellation of Treatments
Individualized with engaged client
Sequenced and strength-based
Safety, Stabilization, skill building, therapeutic alliance,
Trauma processing, narrative integration, meaning of self identity
Psycho-education to normalize symptomatology
Bottom-up and top-down treatments
Build Therapeutic Alliance Regardless of Diagnoses
Attachment repair, mirror neurons, holding environment
Darwin meets Freud!
Affect & Physiological Regulation (physical and emotional regulation)
Widen the window of distress tolerance
Recounting trauma can re-traumatize – vicarious trauma considerations
Impaired Integration & Transition of Developmental Stages
Implicit memories & narrative abilities - consider developmental age of client
Critical learning periods: affect regulation, language, concrete/abstract thinking
Considering Trauma Treatments
Treatment and assessment are ever-evolving
Circling back to crisis & stabilization with newly acquired skills
Interventions can be in the moment – trusting the client!
Clinical agility and attunement
It’s never one thing……
Chemical reactions are cascades of reactions & catalysts
People are walking talking feeling emoting chemical reactions
Emotions are necessary physiological processes dependent on the CNS
Treatments focus on outcome may miss the “Lessons Learned”
Developmental age vs. chronological age
Meet the client developmentally
Under stress we regress (stunted affect, dysregulated behaviors, etc.)
Cyclical groundwork
Attachment, Attunement, Alliance & Affect Regulation
Trust your client to give you metaphors & analogies
Psycho-education of CNS normalizes trauma sequelae
Panic attacks, nausea, somatization
Parasympathetic NS versus Sympathetic NS
Considering Trauma Treatments
Connection & vulnerability – taking worthwhile risks
Brené Brown www.tedtalks.com (20 minute video)
Neuroplasticity: positive physical activity integrates experiences
Simultaneous regulation through combined sequenced therapies
Top-down (cognitive talk-based) & Bottom-up (experiential) therapies
Cognitive Processing Therapy – structured 12 sessions includes writing
CBT with Prolonged Exposure
EMDR – Eye Movement & Desensitization & Reprocessing adults & kids
Sensorimotor Psychotherapy – mind/body/spirit (Pat Ogden)
Attachment, Self-Regulation & Competency – ARC
Margaret E. Blaustein & Kristine M. Kinniburgh (2010)
Experiential learning through repetition rewires brain
Procedural memory strengthens (long-term & implicit)
Integrate implicit and explicit memories to narrative change of IWM
Client is focus, not the trauma
Questions-comments-contributions-insights?
References
Ahrens, J., & Rexford, L. (2002). Cognitive processing therapy for incarcerated
adolescents with PTSD. Journal of Aggression, Maltreatment & Trauma, 6(1), 201-216.
Axelrod, S. R., Morgan, C. A., & Southwick, S. M. (2005). Symptoms of posttraumatic
stress disorder and borderline personality disorder in veterans of Operation Desert
Storm. American Journal of Psychiatry, 162, 270-275.
Blaustein, M.E., Kinniburgh, K.M. (2010). Treating traumatic stress in children and
adolescents: How to foster resilience through attachment, self-regulation , and
competency. New York, Guilford.
Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of
posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting
and Clinical Psychology, 73(5), 965-971.
Classen, C. C., Pain, C., Field, N. P., & Woods, P. (2006). Posttraumatic personality
disorder: A reformulation of complex posttraumatic stress disorder and borderline
personality disorder. Psychiatric Clinics of North America, 29, 87-112.
Courtois, C. (2012, February). New Guidelines for the treatment of complex trauma,
Chevy Chase, Md.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss,
M.P., & Marks, J.J. (1998). Relationship of childhood abuse and household dysfunction to
many of the leading causes of death in adults: The adverse childhood experiences (ACE)
study. American Journal of Preventive Medicine, 14(4). 245-258.
REFERENCES
Heller, D. P. (2012 February) The neurobiology of relationships: Crossing the bridge to
secure attachment and to regain resilience and richness in relationships. Washington, DC
Hesse, E. (1999). The Adult Attachment Interview: Historical and current perspectives. In J.
Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory, research and clinical
applications (pp.395 – 433). New York: Guilford Press.
Jankowski, M.K., Leitenberg, H., Henning, K., & Coffey, P. (2002). Parental caring as a
possible buffer against sexual revictimization in young adult survivors of child sexual abuse.
Journal of Traumatic Stress, 15(3), 235 – 244.
Johnson, D. M., Sheahan, T. C., & Chard, K. M. (2003). Personality disorders, coping
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REFERENCES
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REFERENCES
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