M4. Lesson 4.5: Post Traumatic Stress Disorders

Question 1

What do trauma and stressor-related disorders occur in response to?

Answer 1

Trauma- and stressor-related disorders occur in response to exposure to a traumatic or very stressful negative event, like sexual abuse, a natural disaster, a car accident, or violent assault.

Question 2

What is our response to trauma?

Answer 2

How we respond to trauma is variable, with some reactions and disorders clearly being based on anxiety and fear, but with other reactions being marked by anhedonia and dysphoria

Question 3

What does the trauma and stressor-related disorder section include?

Answer 3

The DSM-5 trauma- and stressor-related disorders section includes:

1. two childhood disorders (Reactive Attachment Disorder and Disinhibited Social Engagement Disorder),
2. Posttraumatic Stress Disorder (PTSD),
3. and Acute Stress Disorder.

Question 4

What is the criteria to receive a diagnosis of PTSD?

Answer 4

According to the DSM-5, for a person to receive a diagnosis of Post-Traumatic Stress Disorder (PTSD), they must meet the following 8 criteria (APA, 2013).

1. First, as mentioned, the person must have been exposed to a traumatic or stressful event such as actual or threatened death, serious bodily harm, or sexual violence. The person may have experienced the event themselves, witnessed to happening to somebody else, or learned that a close family member or friend was exposed to a trauma (APA, 2013).
2. Second, the person has intrusive symptoms such that they re-experience the trauma, for example through unwanted memories, nightmares, or flashbacks that are related to the traumatic event. These symptoms are not within the person’s control, which can be particularly distressing for those with PTSD.
3. Third, the person avoids trauma-related stimuli (e.g., thoughts, emotions, reminders) (e.g., people, places, objects). They do so in order to avoid the overwhelming fear response that arises when they are around trauma-related stimuli. For some people with PTSD exposure to trauma-related stimuli can lead to an increase in intrusive thoughts, nightmares, or flashbacks. Some examples of things that people might avoid include certain locations, people, conversations or memories, rooms in their homes, etc.
4. Fourth, the person experiences negative changes in mood or cognition related to the traumatic event (e.g., inability to remember important parts of the event, exaggerated negative beliefs, negative emotions and the inability to experience positive emotions).
5. Fifth, the person experiences significant changes in arousal and behaviour (e.g., irritability, hypervigilance, sleep disturbance) (APA, 2013). For example, it is not uncommon for individuals with PTSD to experience insomnia or to be hypervigilant to concerns about safety. This overarousal sometimes results in feeling tense, “keyed up” or on edge. It is also common for individuals with PTSD to have exaggerated startle responses, compared to people without PTSD.
6. Sixth, the disturbances in mood, cognition, and behaviour must occur for at least 1 month.
7. Seventh, and they must cause clinically significant distress or impairment in important areas of functioning (e.g., social, occupational).
8. Eighth, the disturbances should not be better explained by the effects of a substance or another medical condition. In addition to making a diagnosis of PTSD, a psychologist can specify if the person also has symptoms of dissociation and/or if they have delayed expression of symptoms (i.e., full diagnostic criteria are not met until at least 6 months after the traumatic event) (APA, 2013).

Question 5

What is the separate diagnostic criteria for trauma and stressor-related disorders for children 6 years and younger?

Answer 5

The DSM-5 has separate diagnostic criteria for children 6 years and younger. Some important differences are that in young children, intrusive memories may not look the same as they do in adults. In children, intrusive memories can be expressed through repetitive play. Children can also experience less interest in play, an exaggerated startle response, and they may have extreme temper tantrums (APA, 2013).

Question 6

Why do some individuals, when exposed to trauma, develop PTSD but others do not?

Answer 6

The discrepancy between the rate of trauma exposure and the rate of PTSD has led researchers to try to identify factors that increase the likelihood of developing PTSD after exposure to a trauma. One such identified factor is event centrality (Berntsen & Rubin, 2006), or how central we come to see that event to our lives, memories, and identity.

Question 7

What are the two versions of the CES?

Answer 7

The CES has a full 20-item version and a short-form 7-item version. Both have high reliability and validity

Question 8

What are the 3 factors of the CES?

Answer 8

The CES has three factors. It measures the extent to which the individual’s traumatic memory:
1) becomes a reference point for everyday inferences;
2) represents a turning point in the individual’s life story; and
3) becomes a reference point for their personal identity. Each of these factors are positively related to PTSD (Robinaugh & McNally, 2011).

Question 9

Why does each factor of the CES contribute to symptoms of PTSD?

Answer 9

Berntsen and Robin (2006) proposed that the availability heuristic (Tversky & Kahnman, 1973) helps to explain the relationship between the first factor and PTSD. For example, if the trauma memories are highly accessible, then the individual will overestimate the frequency of such events in everyday life, leading to unnecessary worries, precautions, and other traumatization symptoms (Berntsen & Rubin, 2006).

The second factor was developed from research on how trauma can profoundly change a person’s outlook (Janoff-Bulman, 1989). Berntsen and Rubin (2006) proposed that symptoms of PTSD may be exacerbated when the individual focuses on aspects of their life that can be explained by referencing this turning point in the life story, while discounting aspects that defy these references (Berntsen & Rubin, 2006).

Lastly, the third factor was developed from research that suggests that an individual may perceive a trauma as causally related to a stable characteristic of the self (Abramson, Seligman, & Teasdale, 1978; Berntsen & Rubin, 2006). Therefore, this factor is proposed to be related to PTSD when individuals attribute the trauma to stable negative identity characteristics

Question 10

What is the overall impact of the CES on PTSD?

Answer 10

Overall, research on event centrality supports the autobiographical memory model of PTSD, which purposes that PTSD symptoms result from the over integration of the trauma into one’s memory, identity, and understanding of the world (Berntsen & Rubin, 2006; Rubin, Berntsen, & Bohni, 2008; Rubin, Boals, & Berntsen, 2008).

Question 11

Since the construction of CES, what has research demonstrated?

Answer 11

Since the construction of the centrality of events scale (Berntsen & Rubin, 2006) research has demonstrated a robust positive relationship between event centrality and PTSD for a range of trauma types and participant populations.

For example, the positive relationship between event centrality and PTSD has been found for individuals exposed to child sexual abuse (Robinaugh & McNally, 2011), military combat (Brown, Antonius, Kramer, Root, & Hirst, 2010), terrorist attacks/bombings (Blix, Solberg, & Heir, 2014), physical injury or assault/abuse, illness, exposure to death, sexual assault/abuse, accidents, and natural disasters (Teale Sapach et al., 2019; Barton, Boals, & Knowles, 2013). The positive relationship between event centrality and PTSD has also been found for a range of participant samples, including community members (Rubin, Dennis, & Beckham, 2011; Ogle et al., 2014), undergraduate students (Barton et al., 2013; Berntsen & Rubin, 2006; Broadbridge, 2018; Fitzgerald, Berntsen, & Broadbridge, 2016), treatment-seeking individuals (Boals & Murrel, 2016; Silva et al., 2016), and military veterans (Brown et al., 2010). This relationship between event centrality and PTSD is also evident for adults ranging from 18 to 93 (Barton et al., 2013; Berntsen, Rubin, & Siegler, 2011; Wamser-Nanney, 2019; Ogle et al., 2013; Boals, Hayslip, Knowles, & Banks, 2012).

Question 12

What are the nuances in the relationship between centrality and PTSD?

Answer 12

However, there are nuances in the relationship between event centrality and PTSD for certain participant characteristics. For instance, younger adults (Boals et al., 2012) and women (Boals, 2010) are more likely to centralize a traumatic event and develop PTSD compared to older adults and men, respectively. Therefore, the difference in event centrality may help to explain the higher prevalence of PTSD in these populations (i.e., young adults and women; Van Ameringen et al., 2008).

Question 13

Are there certain types of trauma?

Answer 13

Yes. There are certain types of trauma that have a greater impact on the development and maintenance of PTSD.

Question 14

What are interpersonal traumatic events?

Answer 14

Interpersonal traumatic events that are purposefully caused by other people contribute the most to PTSD risk and symptom severity.

Question 15

What is the type of trauma that has less impact on PTSD?

Answer 15

Events that occur by accident or by natural disaster have a far less impact on the risk for PTSD compared to interpersonal traumas

Question 16

Why are interpersonal traumas stronger?

Answer 16

There are several reasons explaining why interpersonal traumas are so powerful in increasing a person’s risk and severity of PTSD. In interpersonal traumas, the appraisal of threat tends to be higher, and people tend to experience a higher level of distress and decreased sense of safety in the world. In addition, interpersonal traumas can affect people’s ability to effectively interact with others (Charuvastra & Cloitre, 2008).

Question 17

What is a significant risk factor for the PTSD for childhood?

Answer 17

In childhood, the bond between the caregiver and child helps to establish a sense of safety and emotion regulation. Abuse during childhood is a significant risk factor for the PTSD later on in life and it plays an important role in dysregulating the stress response system (Charuvastra & Cloitre, 2008).

Question 18

What is a protective factor against stress?

Answer 18

Positive social interactions act as a protective factor against stress.

Question 19

Where does the value of social support lie?

Answer 19

The value of social support lies in the perceived helpfulness and sense of connectedness with others. It is not the quantity of social support that is protective against PTSD, but rather it is the match between what the person needs and the type of support that is offered. Social support can decrease feelings of distress and increase safety and a sense of belonging. If a person feels isolated ostracized, blamed, or feels unsupported by their relationships, this can contribute to the onset and severity of PTSD symptoms

Question 20

What is social support?

Answer 20

Social support before and after an exposure to a traumatic event plays an important role in determining a person’s risk and severity of PTSD (Charuvastra & Cloitre, 2008). Social support helps people to effectively regulate their emotions, which is central for recovery from PTSD. If a person is not able to effectively manage intense emotions and memories, they are more likely to re-experience traumatic events and use avoidance as a way to cope with difficult emotional experiences. Social support plays an important role throughout life.

Question 21

What can negative relationships reinforce?

Answer 21

Negative relationships can reinforce the belief that the world is a place that is unsafe and harmful.

Question 22

Where can the risk for PTSD begin in terms of biological factors?

Answer 22

In a review on the biological risk factors for PTSD, Yahyavi, Zarghami, and Marwah (2014) found that the risk for PTSD can begin in utero.

Question 23

What part of the brain is affected in the utero?

Answer 23

The HPA axis, which plays an important role in the stress response, is greatly affected by early development. Maternal exposure to trauma, for example, can lead to changes in the fetal brain that disrupt gene expression.

Question 24

What can the affect on the brain in the baby do (in terms of PTSD)?

Answer 24

Changes in these biological systems disrupts emotion regulation and the ability to effectively manage stress. However, there is growing consensus that genetic markers do not act in isolation but interact with environmental factors to impact a person’s vulnerability to developing PTSD (Klengel & Binder, 2015). In addition, the genetic risk factors for PTSD are complex and the biologic pathways for this disorder are not fully understood

Question 25

What did APA do in terms of treatments for PTSD?

Answer 25

The American Psychological Association (APA) has developed a list of empirically supported treatments (ESTs) that are indicated for the treatment of PTSD. Within this list, the APA differentiates between treatments that are conditionally recommended and strongly recommended.

Question 26

What evidence do treatments that are conditionally recommended have?

Answer 26

Treatments that are conditionally recommended all have evidence that indicates that they can lead to good treatment outcomes. However, the evidence may not be as strong, the balance of treatment benefits and possible harms may be less favorable, or the intervention may be less applicable across treatment settings or subgroups of individuals with PTSD (APA, 2017). Additional research on these conditionally recommended treatments might lead, with time, to a change in the strength of recommendations in future guidelines.

Question 27

What does the therapist do in CBT?

Answer 27

The therapist works with the client to identify thoughts, behaviours, and emotions which might be having negative effects on the client’s wellbeing and uses various skills to alter these as needed. As applied to trauma, oftentimes this takes the form of helping clients learn how to modify and challenge unhelpful beliefs related to the trauma. Modifying and challenging these unhelpful beliefs is meant to modify the client’s emotional and behavioural reactions into ones that are more positive.

Question 28

What are the strongly recommended treatments for PTSD?

Answer 28

At present, the APA strongly recommends four treatments for individuals with PTSD, all which are variations of Cognitive Behavioural Therapy (CBT). These treatments include: Prolonged Exposure Therapy, Cognitive Processing Therapy, Cognitive Therapy, and traditional Cognitive Behavioural Therapy (APA, 2017).

Question 29

What is CBT?

Answer 29

CBT is a form of therapy that focuses on how individuals’ thoughts, behaviours, and emotions are interrelated.

Question 30

What technique is often incorporated in the strongly recommended treatments for PTSD?

Answer 30

Oftentimes a technique called exposure is incorporated into the abovementioned treatments. Exposure is a process whereby the client gradually approaches trauma-related memories, feelings, and situations.

Question 31

How can exposure be conducted?

Answer 31

It can be conducted in a number of ways, including describing the trauma narrative aloud, listening to an audio recording of the trauma narrative, writing out the trauma narrative and/or reading it aloud, and physically going to situations which are feared and/or reminders of the trauma.

Question 32

What are the different methods of exposure often referred to as?

Answer 32

These different methods of exposure are often referred to as imaginal exposure (occurring within the imagination), and in-vivo exposure (occurring in real life).

Question 33

What will the client learn from exposure?

Answer 33

By facing what has been avoided, the client presumably will learn that the trauma-related memories and cues are not dangerous and do not need to be avoided. By extension, any associated distressing thoughts, feelings, and sensations will be diminished.

Question 33

What will the client learn from exposure?

Answer 33

By facing what has been avoided, the client presumably will learn that the trauma-related memories and cues are not dangerous and do not need to be avoided. By extension, any associated distressing thoughts, feelings, and sensations will be diminished.

Question 34

What do individuals randomly assigned to exposure therapy have?

Answer 34

Individuals randomly assigned to exposure therapy have significantly greater pre- to posttreatment reductions in PTSD symptoms compared to supportive counseling, relaxation training, and treatment as usual including pharmacotherapy.

Question 35

What is the meta-analysis on the effectiveness of PTSD?

Answer 35

A meta-analysis on the effectiveness of PTSD showed that clients treated with PE fared better than 86% of patients in control conditions on PTSD symptoms at the end of treatment. Furthermore, among PE participants, 41% to 95% lost their PTSD diagnosis at the end of treatment (Jonas et al., 2016), and 66% more participants treated with exposure therapy achieved loss of PTSD diagnosis, compared to those in waitlist control groups

Question 36

CPT has influenced what in PTSD patients?

Answer 36

CPT has been found to influence a clinically significant reduction in PTSD, depression, and anxiety symptoms in sexual assault and Veteran samples, with results maintained at 5 and 10 year post treatment follow-up (Cusack et al., 2016; Resick et al., 2012; Watts et al., 2013). Furthermore, rates of participants who no longer met PTSD diagnosis criteria ranged from 30% to 97% and 51% more participants treated with CPT achieved loss of PTSD diagnosis, compared to waitlist, self-help booklet and usual care control groups (Jonas et al., 2016).

Question 37

What has research said about CBT?

Answer 37

Traditional CBTs have also been shown to be more effective than a waitlist (Power et al., 2002), supportive therapy (Blanchard et al., 2003) and a self-help booklet (Ehlers et al., 2003). Researchers have also compared various components of CBT (i.e., imaginal exposure, in vivo exposure, cognitive restructuring) with some mixed results. Marks et al. (1998) compared exposure therapy (that included five sessions of imaginal exposure and five sessions of in vivo exposure), cognitive restructuring, combined exposure therapy and cognitive restructuring, and relaxation in an RCT.

Question 38

What does research suggest with exposure and cognitive restructuring?

Answer 38

Exposure and cognitive restructuring were each effective in reducing PTSD symptoms and were superior to relaxation. Exposure and cognitive restructuring were not mutually enhancing when combined. Furthermore, research suggests that 61% to 82.4% of participants treated with traditional CBT lost their PTSD diagnosis and 26% more CBT participants than waitlist or supportive counseling achieved loss of PTSD diagnosis (Jonas et al., 2016).

Question 39

What other treatments that the APA conditionally recommends for patients with PTSD?

Answer 39

There are also a number of treatments which the APA indicates are conditionally recommended for the treatment of PTSD. These include Eye Movement Desensitization and Reprocessing Therapy (EMDR), Narrative Exposure Therapy (NET) and Medication