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PsicoTraumatologia



Post-Traumatic Stress Disorder (PTSD)

Liliana Speed, Ed.D. (June 1999)

(Lavoro presentato al Seminario su Psicologia dell'Emergenza del 25 e 26 Giugno 1999,
organizzato dall'Ordine degli Psicologi della Provincia di Bolzano)



The first experience which I personally can describe and which I found to have been shared by many others of my colleagues relates to our reaction when a team of experts came to help us help the victims of the Oklahoma City Bombing. These experts came from all parts of the United States to impart their superior knowledge. My first reaction was "I am a psychologist who has been practicing for 20 years ... what makes them the experts?" I would imagine that many of you in the audience today might have had some of these thoughts and might have felt some of the feelings that we felt. It is with humility therefore, and well aware of the fact that I am no more of an expert than anyone else in here. But with the knowledge that I do have some experiences which I can share with all of you and hopefully some of them may be found useful. Some of my presentation will focus on adults but mostly on children because that is the focus of my Division at the University of Oklahoma.



This is an abbreviated version of the criteria for PTSD in DSM-IV.

POST-TRAUMATIC STRESS DISORDER - FROM DSM-IV

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.
  2. The person’s response involved intense fear, helplessness, or horror.

B. The traumatic event is persistently reexperienced:

  1. Recurrent and intrusive distressing recollections of the event. Note: In young children, repetitive play may occur.
  2. Recurrent distressing dreams of the event.
  3. Acting or feeling as if the traumatic event were recurring.
  4. Intense distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
  5. Physiological reactivity.

C. Persistent avoidance of stimuli associated with the trauma.

D. Persistent symptoms of increased arousal.

E. Duration of the disturbance is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational,
      or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months.
Chronic: if duration of symptoms is 3 months or more.

Specify if:

With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

From:
Desk Reference to the Diagnostic Criteria from DSM-IV. American Psychiatric Association, Washington, D.C. (1994).



These are the diagnoses which have also been associated with trauma victims.

Common Psychiatric Disturbances Found Among Children in Disasters

RankDisorder
1Anxiety disorder, avoidant disorder
2Anxiety disorder, separation-anxiety disorder
3Sleep-terror disorder
4Overanxious disorder
5Simple phobia
6Agoraphobia, without panic
7Post-traumatic stress disorder, acute
8Post-traumatic stress disorder, chronic
9Attention-deficit disorder with hyperactivity
10Attention-deficit disorder, residual type

From:
Frederick, C.J. (1985). Children traumatized by catastrophic situations. In Eth, S. and Pynoos, R.S. (Eds.), Post-traumatic Stress Disorder in Children. American Psychiatric Press, Inc., Washington, DC.



Common Psychiatric Disturbances Found Among Children in Physical Abuse

RankDisorder
1Overanxious disorder
2Anxiety disorder, avoidant disorder
3Sleep-terror disorder
4Post-traumatic stress disorder, acute
5Post-traumatic stress disorder, chronic
6Adjustment disorder
7Attention-deficit disorder, with hyperactivity
8Simple phobia
9Functional enuresis
10Identity disorder

From:
Frederick, C.J. (1985). Children traumatized by catastrophic situations. In Eth, S. and Pynoos, R.S. (Eds.), Post-traumatic Stress Disorder in Children. American Psychiatric Press, Inc., Washington, DC.



Short-term Effects

The most common psychological and behavioral symptoms manifest across all disastrous events, in the short-run, are these: sleep disorders (bad dreams), persistent thoughts of the trauma, belief that another traumatic event will occur, conduct disturbances, hyperalertness, avoidance of any stimulus or situation symbolic of the event, psychophysiological disturbances, regression to enuresis in younger children, along with thumbsucking and more dependent behavior.

Long-term Effects

With particular reference to the children of refugees, the contagious effects of psychic trauma on children when parental figures or surrogates are affected must not be underestimated. Children become exceptionally upset because the usually strong figures in their lives become unstable (Freud and Burlingham 1943). Parental instability can lead to world-destruction fantasies in very young children, because a child’s world collapses when the most stable objects in it lack solidity.

During the severe winter storms and flooding in Boston in 1977 it was reported that high school youngsters in physical education classes displayed a marked increase in blood pressure (Cohen and Ahearn 1980).

Seven months after a devastating tornado in Xenia, Ohio, in April 1974, the psychologists who met with citizens who represented the community found them all weeping while describing their experiences during the tornado, revealing the tenuous quality of their efforts toward repression and problem resolution (Frederick, 1985). It was clear that none of those people had experienced any form of deconditioning or of working through the trauma, which had become imprinted in their psyches. The psychological marks made upon children were detailed, including accounts of how sharing classrooms in other schools and functioning in temporary locations brought intolerable stresses to bear upon both teachers and students. Crowded conditions evoked perceptions of encroachment so that the displaced students from other schools were seen as intruders. Tensions and annoyances mounted, with the result that students developed conduct problems and psychophysiological disorders, while truancy increased. Teachers quit speaking to each other. Symptoms of PTSD were clearly in evidence among the adult and childhood populations of Xenia. With appropriate and timely intervention such problems could have been readily avoided.

Many of these same responses were observed in child victims by mental health workers who were providing intervention following a sniper shooting at a school yard in Los Angeles where 15 persons were shot and 1 young girl died at the site. The assailant, himself, suffered from PTSD, which had stemmed from the deaths of his parents and some siblings in the Jonestown massacre in Guyana. The psychological autopsy performed on the assailant disclosed both acute and chronic traumatic effects brought about by Jonestown while the assailant was in his late teens.

Paardekooper (1999) reported on a study on south Sudanese children who were compared to a group of Ugandan children who did not have the experiences of war and flight. Compared to Ugandan children, the Sudanese reported significantly more PTSD-like complaints such as trouble with sleep, nervousness, traumatic memories, and behavioral problems as well as depressive symptoms and psychosomatic complaints.

The Sudanese refugee children had experienced far more traumatic events than the comparison group. Sudanese children experienced more daily stressors than Ugandese children. This is mainly caused by the situation of poverty in the camps. The refugee children report suffering from lack of food, lack of clothes, lack of school materials; and having to live with poor sanitation and poor medical care. In an environment where there is little means of earning one’s own living, where one is depending on food rations and where there is a strong presence of bureaucracy, there are few opportunities to use "problem-focused" coping strategies. Thus it is hardly surprising that looking for distraction by seeking the company of others, wishful thinking, and praying are the most commonly used coping strategies.

The lay-out of refugee camps is usually not very suitable for children. They have lost a considerable part of their social network by fleeing from their place of origin and we may assume that their parents, who are also traumatized by war, are less capable of giving support. In particular, the children complain of lack of emotional support, socializing, and material support.

Almqvist and Broberg (1999) studied 50 Iranian refugee preschool children who were first evaluated 12 months after arriving in Sweden, 39 were reevaluated in a follow-up study 2 ˝ years later. The investigation focused on: the effect of exposure to organized violence, the age, gender, individual vulnerability, parental functioning, and peer relationships on the children’s well-being and adjustment. The investigators found that the mothers’ emotional well-being predicted emotional well-being in children, whereas children’s social adjustment and self-worth were mainly predicted by the quality of their peer relationships. Refugee children’s adaptation is the result of a complex process involving several interacting risk and protective factors. The authors state that for many refugee children, current life circumstances in the host countries, such as peer relationships and exposure to bullying, are of equal or greater importance than previous exposure to organized violence.

Increased vulnerability also appears to be an important risk factor for developing long-lasting posttraumatic stress symptomatology in children exposed to organized violence. In this study of preschool children, the boys appeared to be more severely affected than girls.

Parental Influence

As previously noted, the mother’s emotional well-being predicted emotional well-being in children, a result that is consistent with other investigations of refugee children (Ajdukovic and Ajdukovic, 1993; Garbarino, 1991). Mental health problems in mothers seems to be the most important predictor of overall poor adaptation in the child (Almqvist and Broberg, 1999).

Peer Relationships

Peer relationships, if positive, promoted emotional well-being and good adaptation according to the parents, while negative peer relationships determined low global self-worth and poor social adjustment. This finding is in line with other studies showing the importance of children’s peer relationships for their future adjustment (Parker and Asher, 1987).

Relocation does not seem to be an event as harmful as at first one might presume. L.M. Najarian et al. (1996) presents us with research which compares two groups. One group of children who were relocated after the Armenia earthquake of 1988 and a group of children who remained in the disaster area. Their hypothesis that relocated children would display more severe PTSD symptoms was not supported. Their recommendation was therefore that relocation should be strongly considered as an alternative to catastrophic situations where rebuilding cannot take place for an indefinite time.

B. Pfefferbaum et al. (1999) in a large study (N=2,722) following the OKC bombing of 1995 tells us that the degree of physical, media, and emotional exposure are significant factors in the severity of PTSD. Of note, television exposure of school age children was a stronger predictor of PTSD than either physical or emotional exposure. When personal emotional consequences are low the exposure served as a traumatic perpetuating emotional and physiologic reactivity.

These symptoms all necessitate focused attention upon them in treatment. Favorable prognosis is lessened by lack of treatment and length of time given to specific facets of the problem. The longer the symptoms continue, treated or untreated, the poorer the prognosis. When PTSD is present but missed, which is a frequent occurrence in younger age groups, inappropriate treatment is given, if any at all.

Children remember basic sensory stimuli, such as sounds or colors, in traumatic situations. Cognitive confusion occurs in perception. Children will recall the awesome sounds and colors of a tornado, the rumble and rattling of an earth quake, shots from the gunfire of police or others, olfactory stimuli from debris, or the closeness of crowded living conditions. These more-primitive responses overwhelm the egos of children since, many of the usual adult defense mechanisms such as intellectualization, rationalization, and denial have not developed in prepubescent children.

The victim can, and often does, become a victimizer. Sexually molested children tend to molest others. Children who are physically abused are apt to become abusers. Albert De Salvo, the Boston Strangler, stated that he was beaten with a belt every night, whether he misbehaved or not. Consonant with the traumatic incidents that have evoked serious mental and emotional problems, especially PTSD, victims frequently become suicidal and self-destructive in their behavior. Suicide ranks among the first 10 leading causes of death in adults, and third in persons under the age of 20.

These are some transparencies of the observed vs the expected incidence of PTSD, the first table in children, the second in adults who experienced different types of traumatic events.



Post-Traumatic Stress Disorder in Children
Experiencing Different Types of Traumatic Events

  NObservedExpected
Disasters503010
Child Molestation505010
Physical Abuse503510
Total15011530
Disastersx2 = 15.04df = 1p = .0001
Child Molestationx2 = 63.37df = 1p = .0001
Physical Abusex2 = 23.27df = 1p = .0001
All forms of traumax2 = 94.18df = 1p = .0001

From:
Frederick, C.J. (1985). Children traumatized by catastrophic situations. In Eth, S. and Pynoos, R.S. (Eds.), Post-traumatic Stress Disorder in Children. American Psychiatric Press, Inc., Washington, DC.



Post-Traumatic Stress Disorders in Adults
Experiencing Different Types of Traumatic Events

  NObservedExpected
Natural disasters1004020
Human-induced catastrophes502510
Hostages1006820
Physical assault1006520
Total35019870
Natural disastersx2 = 8.59df = 1p = .003
Human-induced catastrophesx2 = 8.61df = 1p = .003
Hostagesx2 = 44.82df = 1p = .0001
Physical Abusex2 = 39.61df = 1p = .0001
All forms of traumax2 = 34.90df = 1p = .0001

From:
Frederick, C.J. (1985). Children traumatized by catastrophic situations. In Eth, S. and Pynoos, R.S. (Eds.), Post-traumatic Stress Disorder in Children. American Psychiatric Press, Inc., Washington, DC.



Incidence of PTSD in Adults and Children
Experiencing Different Traumas

  Adult (57%)Child (77%)Total
Yes198115313
No15235187
Total350150500

From:
Frederick, C.J. (1985). Children traumatized by catastrophic situations. In Eth, S. and Pynoos, R.S. (Eds.), Post-traumatic Stress Disorder in Children. American Psychiatric Press, Inc., Washington, DC.



These are the most commonly observed signs in children with exposure to trauma.


Signs to Recognize in Children with Exposure to Trauma

1. Sleep disturbances that continue for more than several days.

2. Separation anxiety or clinging behavior, such as a reluctance to return to school.

3. Phobias about distressing stimuli (e.g., a school building, TV scene, or person) that remind the victim of the traumatic event.

4. Conduct disturbances, including problems that occur at home or at school, which serve as responses to anxiety and frustration.

5. Doubts about the self, including comments about body confusion, self-worth, and desire for withdrawal.


Treatment Techniques

1. Psychotherapy

Merely talking, however, will not suffice in undoing serious psychic trauma in either adults or children.

A. Trauma mastery must be incident-specific for specific resolution of the problem. It also must be emphasized that extreme caution must be taken against moving too abruptly into incident-specific replays, on the one hand, and avoiding any focus upon them, on the other. The defense of avoidance, both by the victim and by the therapist, is the most commonly cited defense in the literature.

B. Cognitive-behavioral techniques such as relaxation prior to the process enables the stressors to be tolerated and accepted for relearning purposes.

C. This process is appropriate for both adults and children. While this may not be possible for the Kosova refugees it is possible to design a trip "in vitro" through cognitive-behavioral reenactment and reexperiencing of the geographical location and psychological impressions.

D. Normalization of the victims feelings is an extremely vital and important component of the verbal therapies. The victims must realize that they are not abnormal for experiencing turbulent, emotional responses.

E. Universalizing the experience helps to reduce anxiety and to provide the support needed under such stressful conditions.

F. There is a need to provide psychological immunization. It is vital to allow a desensitization process be placed along with any other type of therapy.

It is recommended by some authors that various dimensions of the disaster be relived by showing slides and scenes, by role playing what individuals did and what they might do if the catastrophe were to occur again. This latter is extremely important in providing the victim with a sense of mastery. The support of family and friends, as well as therapists, is greatly underscored. Encouraging socialization, utilization of community resources, and asking extended family members to be involved in the healing process is vital. Again, and strongly emphasized is the process of discouraging the "avoidance" response and encouraging the catharsis or desensitization is the dual process recommended above.

2. The Coloring Storybook

This method was used by mental health workers following a tornado in Omaha, Nebraska in 1975. The coloring book should be one which describes the traumatic event, and is given to the child to color with the request that the child relate it to himself or herself.

3. Drawings

A. Structured. A structured drawing is one in which the child is told what to draw. For example, the child might be instructed to draw his or her house at the time of a tornado or earthquake and to put significant beings in the drawing, such as members of one’s own family or pets.

B. Unstructured. The child is given little or no instruction about what to draw. Youngsters may be told to draw whatever they feel is important or would like to draw.

4. Instruction Booklets

An instruction booklet developed by workers at the San Fernando Valley earthquake in 1971 and published in 1973 focused upon information of use to both adults and children.

5. Play Therapy

Most experienced therapists find play therapy of use with young children because it helps in the communication of fears without placing importance upon verbal skills. Play therapy of course also reduces the fear in children of too much disclosure and possible reprisals.


References

Overall References:

A. Almqvist, K. and Broberg, A.G. (1999). Mental health and social adjustment in young refugee children 3 ˝ years after their arrival in Sweden. J. Am. Acad. Child Adolesc. Psychiatry, 38(6):723-730.

Sub-references from above reference:

Ajdukovic, M. and Ajdukovic, D. (1993). Psychological well-being of refugee children. Child Abuse Negl, 17:843-854.

Freud, A. and Burlingham, D.T. (1943). War and Children. London: Medical War Books.

Garbarino, J. (1991). Developmental consequences of living in dangerous and unstable environments: the situation of refugee children. In: The Psychological Well-Being of Refugee Children: Research, Practice and Policy Issues, McCallin, M. (Ed.). Geneva: International Catholic Child Bureau, pp. 1-23.

Parker, J.G., Asher, S.R. (1987). Peer relations and later personal adjustment: are low accepted children "at risk"? Psychol. Bull., 102:357-389.

B. Frederick, C.J. (1985). Children traumatized by catastrophic situations. In Eth, S. and Pynoos, R.S. (Eds.), Post-traumatic Stress Disorder in Children. American Psychiatric Press, Inc., Washington, DC.

Sub-references from above reference:

Cohen, R.E. and Ahearn, F.L. (1980). Handbook for Mental Health Care Victims. Baltimore: Johns Hopkins University Press.

Desk Reference to the Diagnostic Criteria from DSM-IV. American Psychiatric Association, Washington, D.C. (1994).

Freud, A. and Burlingham, D.T. (1943). War and Children. London: Medical War Books.

Najarian, L.M., Goenjian, A.K., Pelcovitz, D., Mandel, F., Najarian, B.
(1996). Relocation after a disaster: posttraumatic stress disorder in
Armenia after the earthquake. J. Am. Acad. Child Adolesc. Psychiatry,
35(3):374-383., March.

D. Paardekooper, B., de Jong, J.T.V.M., Hermanns, J.M.A. (1999). The psychological impact of war and the refugee situation on South Sudanese children in refugee camps in Northern Uganda: An exploratory study. J. Child Psychol. Psychiat., 40(4):529-536.

E. Pfefferbaum, B., Moore, V.L., McDonald, N.B., Maynard, B.T., Gurwitch, R.H., Nixon, S.J. (1999). The role of exposure in posttraumatic stress in youths following the 1995 bombing. The Journal of the Oklahoma State Medical Association, 92(4), April.



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