PTSD: Post Traumatic Stress Disorder
Symptoms and Diagnosis
Symptoms and Diagnosis -According to the DSM-IV, there are three main categories of symptoms for PTSD. In order to achieve a diagnosis, the individual must exhibit a certain number of symptoms under each classification. -It is also important to note, that in addition to meeting the specified number of symptoms in each category, the individual must experience the symptoms for at a period of at least one month. -Interestingly, the DSM-IV also cites a criterion for functional impact, listing that "The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of function." 3 Main Categories 1. Intrusive Recollection- The traumatic event is persistently experience in at least one o the ways listed below. (1 out of 5 must be present) • 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. • Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content. • 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 upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur. • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. • Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 2. Avoidance/Numbing symptoms- The individual continually avoids stimuli associated with the traumatic experience and demonstrates a generalized lack of responsiveness. *Note, these symptoms were NOT present before the exposure to the traumatic event. (3 out of 7 must be present) • Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect (e.g., unable to have loving feelings) • Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) 3. Hyper arousal symptoms - Persistent symptoms of increased arousal. *Note, these symptoms were NOT present before the exposure to the traumatic event. (2 out of 5 must be present) • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hyper-vigilance • Exaggerated startle response (The entire Symptom Note card contains information cited from the DSM-IV, 2000 and the United States Department of Veterans Affairs 2010.)
Etiology and Prevalence
Etiology and Prevalence Etiology- According to Dr. Bradley D. Grinage in an article (Grinage, 2003) for the AAFP (American Academy of Family Physicians), the etiology of PTSD is currently unknown, although research has examined various factors in populations that have developed the disorder. • 6.8% of the population in the United States is thought to have PTSD. (Bonder, 2010). • o Genetics- Recent research have uncovered a potential link between the likelihood of developing PTSD and genetic predisposition. Grinage states that those individuals who personally have a pre-existing condition of anxiety of depressive disorder or a family history of these conditions are at a higher risk of developing PTSD after being exposed to a traumatic event within the parameters and contexts listed in the DSM-IV. (Grinage, 2003). o Environment- -Types of Trauma Associated with PTSD • War- Both individuals involved in fighting the war and civilians caught in the crossfire may be at risk for developing PTSD depending on the factors mentioned in previous note cards. • Terrorism- Dehumanizing acts of violence that target a specific population with the intent to intimidate and terrorize the targeted group. • Violence & Abuse- Includes intimate partner violence, sexual and physical abuse, childhood molestation and community violence. • Natural Disasters- Like tornadoes, tsunamis, hurricanes, famines and droughts. • Invasive Medical Procedures- Recent research has examined the possibility of traumatic medical experiences like treatment for cancer and skin grafts associated with severe burns may lead an individual to develop PTSD. (Bonder, 2010), (National Center for PTSD, 2010). o Neurological Resilience- Bonder describes a person's prior state of health and function as an important predictor in how the recovery process with the individual with progress. o Physical Changes- Memory Pathways- Changes in memory pathways within the brain, especially in the hippocampus (which deals with processing and storing memories) are obvious in individuals with PTSD. (Bonder, 2010). Cortisol Levels- Cortisol is a hormone that is released by the adrenal glands during the "fight or flight" response. Typically, there is a feedback mechanism that inhibits the release of more hormone after the threat is resolved. Research has suggested that in patients with PTSD there is a disassociation between the components in the feedback loop. This mismatch affects how memories of the trauma are formed in the brain, and can in turn lead to higher levels of cortisol in the body when the individual is exposed to stimuli that trigger a flashback or memory related to the traumatic experience. (Grinage, 2003). • Example: According to Grinage, a study demonstrated that rape victims showed lower levels of cortisol recently after the attack, if they also had a history of previous attacks. (Bonder, 2010) (Grinage, 2003).
Implications for Occupational Performance
Implications for Occupational Performance -Generally, the impact of PTSD on performance depends on the severity of the symptoms that are experienced by the individual. • Cognitive Skills- Since the hippocampus (memory processing center) area of the brain is affected by PTSD, the individual may have difficulties following a routine and managing a daily schedule. • ADLs- PTSD has the potential to disrupt an individual's sleep schedule, which can in turn decrease occupational performance in other ADLs like health management or home maintenance. • Social Participation- Stimuli like objects or an environment that is similar or relatable to the context of the traumatic event can trigger a flashback for those with PTSD. If these stimuli are difficult to avoid, the person may begin to restrict their social participation to "stay safe" which negatively impacts this area of occupation. • Academic Performance- Hyper arousal responses may make concentration difficult for individuals with PTSD. Inconsistent sleep cycles, coupled with comorbid conditions like depression could display symptoms like distractibility, lack of motivation, and decreased concentration. (Bonder, 2010).
Assessment
Assessment -The National Center for PTSD which functions under the United States Department of Veterans Affairs lists a plethora of assessment and screening tools that may be used to identify and evaluate individuals with PTSD. -Administration- While certain screenings are available online and can be taken at any time by anyone, more in depth interviews can only be administered by professionals that have attained a graduate level education and certifications that specialize in the treatment of PTSD. (The National Center for PTSD, 2010) -Broad versus Narrow Approaches 1. Broad- These types of assessments examine a wide range of negative and traumatic experiences throughout an individual's lifespan. They do NOT focus on the 17 symptoms categorized into 3 distinct categories or one particularly traumatic event. -Strength- This holistic approach allows the interviewer to appreciate the client's contexts and background before and after the onset of the symptoms. -Weakness- Due to the wide range of this approach, symptoms that are not related to PTSD may be discovered during the process. Given the broad context, it may be difficult to separate co-morbid symptoms from classic PTSD symptoms. 2. Narrow- This type of approach includes highly specified tests that focus on the specific criterion necessary to affirm a diagnosis of PTSD. -Strength- Self-report questionnaires are a common format of testing for the narrow approach and are based off of the 17 symptoms that an individual can exhibit in order to be diagnosed with PTSD. These symptoms severely interfere with the individual's everyday functions, which validates this format of testing because it has the ability to show the professional the impact of the individual's symptoms in daily life. -Weakness- Due to the brief format, narrow approach tools do not have the capacity to delve into the client's contexts and previous level of function which have the potential to offer more information about their current symptoms and difficulties. (The National Center for PTSD, 2007). • Self Report- This tool is effective if it is used as a screening tool for further evaluation. For example. It could be used with members of the military returning from a tour in a war zone to determine a need for further evaluation of PTSD. It is not meant to be used as a diagnostic tool independently and must be used in combination with other measures administered by a professional. • Structured Interview- This type of assessment is administered by a professional with graduate level training (*Must hold a Masters degree in a clinical discipline*) and experience in assessment, trauma and psychology. These tools are highly specialized, have high levels of validity and reliability and if properly administered can affirm or reject a diagnosis of PTSD. (The National Center for PTSD, 2010).
Classification
Classifications 1. Acute- The individual experiences symptoms for less than three months. 2. Chronic- The individual experiences symptoms for at least three months or more. 3. Delayed-In delayed onset, the individual begins to experience symptoms at least six months after the trauma. (The National Center for PTSD, 2010). In order to be diagnosed, an individual must have exposed to a traumatic even that invoked the both of the following responses: a. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. b. The person's response involved intense fear, helplessness, or horror. (Children may display more disorganized behavior.) (The National Center for PTSD, 2010).
Comorbidities
Comorbidities -The National Center for PTSD lists the following conditions as common comorbidities associated with a diagnosis of PTSD. • Acute Stress Disorder- A diagnosis of ASD can often overlap a diagnosis of PTSD, the main difference lies in the fact that ASD must be diagnosed within a month of the trauma, while a diagnosis of PTSD cannot be made until the symptoms have been present for at least one month. Hallmark symptoms of ASD also include disorientation to self, place and time and a feeling as though the individual is living outside of their own body. (National Center for PTSD, 2010). o 80% of those diagnosed with ASD develop PTSD within 6 months. (National Center for PTSD, 2010). • Depression- The traumatic experience may increase symptoms of depression from the individual's pre-morbid condition or the onset of depressive symptoms may occur co-morbidly. It is important to treat both the symptoms of depression and PTSD simultaneously utilizing a variety of methods and supports as soon as the symptoms occur and begin to impact the individual's function. (National Center for PTSD, 2010). • Chronic Pain- In a recent study, it was found that approximately 15% to 35% of individuals with chronic pain in the United States were also diagnosed with PTSD. According to the National Center for PTSD, the manifestation of physical pain may serve as a reminder of the traumatic event to the individual. (National Center for PTSD, 2010). • Alcohol and Substance Abuse- Abuse of substances or alcohol is a common comorbidity that is seen as a way for the individual to self medicate and cope with the symptoms of PTSD. (Bonder, 2010). • Self Harm- This maladaptive coping mechanism is said to serve as a way to deal with stressful and sometimes traumatic situations. According to the National Center for PTSD, one group of individuals being treated for self-harm stated that they had been sexually abused during the course of their childhood. This type of violence is one of the environmental factors that can lead to the development of PTSD. (National Center for PTSD). • Suicide - According to the National Center for PTSD, the risk of suicide attempts increases among those with PTSD either due to the traumatic event or a comorbid condition like depression. o Gender Males-In 2005, 23.19 per 100,000 US male citizens committed suicide. Females- In 2005, 5.65 per 100,000 US female citizens committed suicide. (National Center for PTSD, 2010).
Definition
Definition- According to the National Institute of Mental Health, "Post Traumatic Stress Disorder, PTSD, is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat." (NIMH, 2010)
References
References Americas Heroes At Work. (n.d.). Americas Heroes At Work. Retrieved from http://www.americasheroesatwork.gov/forEmployers/factsheets/FAQPTSD/ Bonder, B. (2010). Psychopathology and function. (4th ed.). Thorofare, NJ: Slack Inc. Ehlers, A., Clark, D. M., Hackmann, A., McManus F., & Fennell, M. J. V. (2005). Cognitive therapy for post-traumatic stress disorder: Development and evaluation. Behavioral Research and Therapy, 43, 413-431. Grinage, B. (2003). Diagnosis and Management of Post-traumatic stress disorder. American Academy of Family Physicians, 12. Retrieved from http://www.aafp.org/afp/2003/1215/p2401.html NIMH • Post-Traumatic Stress Disorder (PTSD). (n.d.). NIMH • Home. Retrieved from http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/complete-index.shtml#pub1 National Center for PTSD Home. (n.d.). National Center for PTSD Home. Retrieved from http://www.ptsd.va.gov//
Research
Research Areas of Research- 1. Accommodations in the Workplace (http://www.americasheroesatwork.gov/forEmployers/factsheets/FAQPTSD/) o A federal website offered displayed information regarding the integration of individuals with PTSD in to the workplace. The process of achieving these accommodations would fit nicely with the basic principles of occupational therapy. Developing effective strategies for this population to achieve functional performance in the area of work would be relevant in the future. 2. Race and Ethnicity o Currently, the effects of race and ethnicity on the diagnosis, treatment, and perception of PTSD are being studied. (The National Center of PTSD, 2010). 3. Psychopharmacology o The effects of different categories of psychotropic medications to treat different symptoms of PTSD are being researched. (The National Center for PTSD, 2010). 4. Natural Disasters o Peoples that have experienced the recent slew of natural disasters (Like individuals living in Japan or those in the Southern United States) could benefit from a screening for PTSD and Early Intervention treatment. (The National Center for PTSD, 2010).
Resources / Awareness
Resources / Awareness -Resources for PTSD can be found based on the type of trauma that was incurred. For example, there are books and websites that are specifically designed to aid veterans that have experienced trauma related to war. There are also resources that are specifically designed for victims of childhood sexual abuse who are dealing with PTSD. -As explained earlier, the federal government website dealing with employment demonstrates an effort to inform the public about issues surrounding PTSD and the basic facts, which will hopefully facilitate effective interaction and functioning in the community between those with and without PTSD. (The National Center for PTSD, 2010), (Bonder, 2010).
Treatment and Prognosis
Treatment and Prognosis -In terms of evidence-based practice, there are three approaches that have been researched and applied to a wide range of clients. In turn the outcomes have been evaluated and it has been determined that these approaches are beneficial in helping to reduce the severity of the symptoms and restoring optimal performance levels in combination with other supports. (The National Center for PTSD, 2010). • Exposure Based Treatments- This category of treatments focuses on the client repeatedly experiencing the trauma. The most popular method is PE or prolonged exposure. This process combines aspects of confrontation and images into the therapeutic process. o It has been found that PE in combination with cognitive therapeutic approaches helps to reduce the severity of symptoms of PTSD. (The National Center for PTSD, 2010). • Cognitive Processing Therapy- In this type of therapy, the main goal is to challenge and modify beliefs related to the traumatic experience. (The National Center for PTSD). o Specialized Strategy: Ehlers and Clark (2005) developed a cognitively based treatment plan for individuals with PTSD that operated under 3 goals. Modifying excessively negative appraisals. Correcting autobiographical memory disturbances. Removing problematic cognitive and behavioral strategies. (Ehlers & Clark, 2005). • EMDR (Eye Movement Desensitization Reprocessing)- This approach uses images to expose the individual to a particular aspect of the trauma, while they are engaged in saccadic eye movements. There is currently research being done to examine whether the response from the client is due to the exposure or the eye movements, since evidence has shown that exposure therapy is an effective medium. (The National Center for PTSD, 2010). • Support Groups- Situations where individuals can communicate emotions and thoughts without fear of being judged can be an effective part of treatment. (Bonder, 2010). • Psychopharmacology- To date, the evidence gathered through trials and research has determined that SSRI's (selective serotonin reuptake inhibitors) are the most effective at treating the three major categories of symptoms associated with PTSD (re-experiencing, avoiding/numbing, and hyper-arousal). o Of these, only 2 are currently approved by the FDA for the treatment of PTSD. Sertraline (Zoloft) Paroxetine (Paxil) • Other medications may be used to treat some of the symptoms associated with PTSD. For example, a sleep aid may be prescribed if hyper-arousal symptoms are severely impacting the individual's ability to function. (The National Center for PTSD, 2010). -All of the aforementioned treatment options can be (and often are) used in collaboration with other disciplines and translate across a variety of contexts. The strategies that the client is being taught through on discipline could be incorporated into the Occupational Therapist's treatment plan and goals as well. • Example- If a client was told that establishing a structured routine prior to and during the sleep preparation process, the OT could work with the client to establish and maintain the routine, which would be working towards fulfilling both discipline's goals for the client.