The video below is the section for Posttraumatic Stress Disorder from Part 7 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 7, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Posttraumatic Stress Disorder
NARRATIVE DEFINITION:
Posttraumatic Stress Disorder (PTSD) is an Trauma- and Stressor-Related Disorder that develops in response to exposure to a traumatic event, characterized by at least one month of symptoms of re-experiencing the traumatic event; avoiding stimuli that recall the event; numbing; and increased levels of arousal. The event may be experienced personally (e.g., being kidnapped), may be witnessed (e.g., observing a violent assault on another person), or may be learned about after the event has occurred (e.g., hearing that your child has been diagnosed with a life-threatening illness). The traumatic stressor involves threatened or actual death, threatened or actual injury, threat to one’s own physical integrity, or threat to the physical integrity of another person.
Re-experiencing: Individuals with PTSD may re-experience their traumas in a variety of ways. Individuals may be plagued with intrusive thoughts, memories, or images of their trauma during waking hours, or they may have recurrent dreams about the trauma. Individuals may experience psychological distress or physiological reactivity when exposed to cues that recall the trauma. In some cases, hallucinations or dissociative flashbacks may occur, causing the individual to feel as if the traumatic event is actually being relived.
It should be noted that children with PTSD often re-experience their traumas in less obvious ways. For example, a child may engage in symbolic repetitive play (e.g., crashing toy cars into each other after being in an automobile accident) or have nightmares that are not explicitly reminiscent of the trauma, such as dreaming about a frightening monster instead of an abusive parent.
Avoidance/Numbing: Avoidance of trauma-related stimuli can also manifest itself in numerous ways. Some individuals with PTSD may attempt to actively suppress thoughts and feelings related to the trauma. Places, people, and activities that recall the event may also be avoided. Individuals may have difficulty remembering important details of the trauma and experience amnesia related to the event. Avoidance of trauma-related stimuli is coupled with a general numbing of responsiveness. Individuals may become uninterested in activities previously important to them, feeling estranged, or isolated. Often, there is a restricted range of affect or a sense of foreshortened future.
Arousal: Increased arousal may be apparent in the traumatized individual’s inability to fall or stay asleep. Individuals with PTSD may be prone to angry outbursts or irritability. These individuals often find that they have difficulty concentrating. Because their sense of safety has been compromised, individuals with PTSD often demonstrate hyper vigilance and an exaggerated startle response.
Other symptoms associated with PTSD include survivor guilt, social withdrawal; self-destructive and impulsive behavior; somatic symptoms; impairment in interpersonal relationships; feelings of hopelessness and despair; feeling incapable or impotent; feelings of being damaged; and marked changes in personality.
A diagnosis of PTSD may also include the specifier With dissociative symptoms, which can be either depersonalization or derealization. Depersonalization is persistent or recurrent experiences of feeling detached from one’s mental process and derealization is persistent or recurrent experiences of unreality of surroundings. The specifier, With delayed expression is used when full diagnostic criteria are not met until at least 6 months after the event.
The lifetime prevalence rate of PTSD in American adults is approximately 8 percent using DSM-IV criteria; the 12-month prevalence among U.S. adults is about 3.5%. The highest rates of the disorder are found in survivors of rape, combat veterans, prisoners of war, and survivors of ethnically or politically motivated imprisonment and genocide. Between 30 percent and 50 percent of such individuals will develop PTSD.
Symptoms of PTSD are especially severe and long-lasting when the traumatic event had a human rather than natural cause (e.g., rape, torture). Good prognosis is associated with symptom onset that occurs shortly after the traumatic event; but symptoms that develop more than six months after the trauma and persist for more than six weeks are associated with lower rates of remission.
Cognitive-Behavioral Therapy is the treatment of choice for PTSD; two forms of CBT, particularly effective for combat PTSD, and hence adopted as treatment choices for soldiers with PTSD by the VA administration, are Prolonged Exposure Therapy and Cognitive Processing Therapy. Eye Movement Desensitatization and Reprocessing (EMDR) also showed evidence of efficacy. Emotion-focused psychotherapy has also shown early promise.
Clients engaged in Prolonged Exposure Therapy are typically guided to practice imagined exposure (called Imaginal Exposure), in which they focus on the memories and emotions associated with the trauma. In Cognitive Processing Therapy (CPT), with the aid of a therapist, clients restructure their cognitions surrounding the traumatic event and learn mechanisms for coping with post-traumatic symptoms. Imaginal Exposure is more effective than are relaxation training or EMDR in reducing avoidance behavior, in reducing the re-experiencing of the trauma, and in maintaining symptom remission after treatment has ended. Proponents of EMDR believe that this method helps the client to reprocess traumatic events more rapidly, but some research indicates that it is no more effective than other forms of Cognitive-Behavioral Therapy, with evidence that the added element of eye movement does not appear to influence the treatment’s efficacy.
Psychological debriefing shows limited evidence of effectiveness; in fact, single-session psychological debriefings may aggravate PTSD symptoms.
Meditation is emerging as an effective form of treatment for combat PTSD. One of the first studies on the effects of Transcendental Meditation on symptoms of PTSD was carried out in 1985 with Vietnam Veterans, and showed positive results. The study was published in the Journal of Counseling Psychology in 1985; scientists randomly assigned Vietnam combat veterans to either Transcendental Meditation (TM) or psychotherapy (generic) treatment conditions. After three months, the TM subjects showed significant improvement in PTSD and related symptoms. Recently, new evidence that Transcendental Meditation is an effective tool for PTSD is in the process of being gathered.
Medication (SSRIs or tricyclic antidepressants) may be used; if flashbacks, derealization, transient psychosis, or avoidance and numbing become too intense or overwhelming, short-term antipsychotic medications may be used.
FLASHCARD:
Post-Traumatic Stress Disorder (PTSD)
1. A Trauma- and Stressor-Related Disorder that develops in response to exposure to a traumatic event (e.g., threatened or actual death or injury), marked by at least one month of symptoms of re-experiencing the traumatic event; avoiding stimuli that recall the event (and numbing); and increased levels of arousal
2. Event may be experienced personally (e.g., kidnap, rape), witnessed (e.g., observing a violent assault on another person), or learned about after event has occurred (e.g., hearing that your child has a life-threatening illness)
3. Survivor guilt, self-destructive behavior, social withdrawal, hopelessness may also develop
4. Children may display symptoms less directly (e.g., repetitive play, nightmares about unrelated phenomena)
5. Twelve-month prevalence among U. S. adults is about 3.5%
6. Not all individuals exposed to traumatic stressors develop PTSD. On average(30 percent to 50 percent of those who survived rape, military combat and captivity, and ethnically or politically motivated imprisonment or genocide, will develop the diagnosis.
Specifiers
1. With dissociative symptoms
A. Depersonalization: detached from mental processes
B. Derealization: Unrealitty of surroudings
2. With delayed expression: full criterea met at least 6 months after the event
Treatments
1. Cognitive-behavioral therapies including Prolonged/Imaginal Exposure, Cognitive Processing, and (more controversially) EMDR, are evidence based and used in treatment
2. VA (combat PTSD): Prolonged Exposure, Cognitive Processing
3. Meditation emerging as an effective treatment choice for PTSD and stress-related disorders
QUESTION:
Tamara, a 32-year-old female, was taken hostage during a bank robbery that occurred six weeks ago. Since that time, Tamara has been having recurrent nightmares about the robbery. While she is awake, Tamara experiences intrusive thoughts about the hostage situation. She reports that she feels detached from others and her own body and has lost interest in activities that she previously enjoyed. Tamara also states that she startles and becomes frightened much more easily than she did before the robbery. In the past six weeks, Tamara has been unable to return to that bank. Based on this information, the most appropriate diagnosis for Tamara would be:
ANSWERS:
A. Acute Stress Disorder.
B. Posttraumatic Stress Disorder, With Dissocitative Symptoms
C. Posttraumatic Stress Disorder, Chronic.
D. Adjustment Disorder.
RATIONALE:
B is correct, as Tamara is experiencing the classic symptoms of PTSD; the specifier “With Dissociative Symptoms” is accurate as she feels detached from her own body. The specifier “Chronic” is not appropriate here and is not used with DSM-5. A is incorrect, as Acute Stress Disorder cannot last more than one month; D is incorrect, as the symptoms are more severe and specific to PTSD than would be the case for Adjustment Disorder.