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Posttraumatic stress disorder,
otherwise known as PTSD.
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Let’s start off by looking at the case
of Jim to put things into context.
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Jim is a 54-year-old combat veteran.
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He spends most of his time at
home and avoids gatherings
with more than only a few people.
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When he went to his niece’s birthday
party, he started sweating,
felt nervous and became
paranoid when a balloon popped.
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Jim had to immediately go
home because he felt unsafe.
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That night, he had vivid nightmares
about his time in combat
and woke up in a cold sweat.
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Well, how would you define
posttraumatic stress disorder?
PTSD is a severe, often chronic
and disabling disorder,
which develops in some persons following
exposure to a traumatic event
involving actual or threatened
injury to themselves or others.
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Symptoms lead to considerable social
occupational and interpersonal dysfunction.
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What types of risk
factors lead to PTSD?
Well, here are a couple.
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Sexually violent relationships such
as rape or childhood sexual abuse,
intimate partner violence
can all contribute.
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So can interpersonal network
traumatic experiences.
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Things like unexpected
death of a loved one,
a life-threatening illness of a child,
or a traumatic event in a loved one.
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And also interpersonal violence.
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Again, childhood abuse or
witnessing violence in the home,
physical assault or being
threatened by someone.
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Exposure to organized
violence like refugees,
being kidnapped or civilian in a warzone.
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And participation in
organized violence,
whether this is combat
exposure, being in a gang,
and other things as well.
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Things like being in a car accident,
exposed to some toxic or chemical.
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The lifetime prevalence of
PTSD ranges from 7 to 12%
in the general adult population
in the United States.
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Let’s go back to the story of Jim.
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So Jim became very distressed
by his nightmares,
intrusive thoughts and inability
to tolerate family functions
without becoming triggered,
paranoid, and upset.
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He was severely injured in combat
and suffers chronic pain for
which he was given disability.
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Since he’s no longer working,
he spends his time at home
and is gradually
becoming very isolated.
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So Jim comes to you, he comes into your
office for a psychiatric evaluation
in the hopes of getting some help so
he can engage more with his family.
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What questions would you ask in
your assessment of Jim for PTSD?
“Tell me about your
experience in combat.”
“What was your experience of danger
during your time serving in the war?”
You really want to revisit
potential triggers to help
change emotional responses
to his memories.
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Ask “How did you initially
respond to recognition
that you were in grave
danger during war?”
And what emotions were
associated with your experience?
Jim tells you that at first, he was
excited to travel with his peers
to fight and defend his country.
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There was great sense of unity within his
troop and he made many friends quickly.
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Then things got serious and his troop
rolled over an IED, an explosive device,
which exploded and he saw
his best friend lose a leg.
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Jim’s physical integrity was not harmed,
but he had excruciating back
pain since that explosion
and he can’t get the image of his friends
losing his limbs out of his mind.
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Jim felt intense fear and
hopelessness during the event.
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Sometimes, he thinks he went
numb and everything felt unreal.
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This makes him feel
guilty because
he wishes he would’ve been able
to react and help his troop,
maybe even protect his friend.
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What else would you ask Jim to assess
his current state of well-being?
What else would you ask Jim to assess
his current state of well-being?
“How did you find yourself
reexperiencing the event?”
Be curious about dreams, flashbacks
and intrusive recollections.
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What people, places and events are
being avoided in the present time?
Be attentive here to signs of isolation,
avoidance of social and
occupational gatherings.
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Be aware of secondary
conditions as a result of this.
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For example, you might inquire if Jim is
feeling depressed from social isolation
and loneliness as well as from
chronic disability and pain.
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How do you respond in situations
when feeling triggered?
Be attentive to the following:
Any limited range of affect from Jim,
feelings of detachment or estrangement.
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And how often do you feel hyperaroused?
Pay attention to whether or not Jim
is having sleeping difficulties,
outbursts of anger or an
exaggerated startle response?
Persistent exaggerated negative
beliefs are common in PTSD.
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Someone like Jim might say
things like “I am all bad,”
“No one can be trusted,”
“The world is complete dangerous,”
or “My whole nervous system is
completely and permanently ruined.”
When diagnosing PTSD, note
the persistence of symptoms
has to be for at least four
weeks following the trauma,
but most patients will present
for treatment many, many months,
sometimes years later.
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Now, when diagnosing PTSD, all of
the following criteria must be met.
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There has to an exposure to
actual or threatened death,
serious injury, or
sexual violence.
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Intrusive symptoms
related to the trauma,
persistent avoidance of stimuli
associated with the traumatic events,
negative alterations in cognition and mood
associated with the traumatic events.
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There has to marked alterations and arousal
and reactivity associated with the trauma.
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The duration of the disturbance
has to be for more than one month
and the disturbance causes
clinically significant distress
that affects social functioning.
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Finally, a diagnosis of
PTSD is only possible
when you’ve ruled other medically
conditions and substance use issues
as well as other
psychiatric disorders.
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When assessing trauma in children,
it’s important to note that
children older than 6 years old
will engage in repetitive play
that will mimic themes or aspects
of the witnessed or
experienced trauma.
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In children, there may be frightening
dreams without any recognizable content.
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So remember, a child may not be able to
directly link their dream to the trauma,
but be attentive to whether or
not they’re having nightmares.
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What are some of the
subtypes of PTSD?
You want to know whether or not it’s
with or without dissociative symptoms
such as depersonalization
and derealization.
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Also, whether or not the PTSD
is with delayed expression.
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For example, full diagnostic criteria
are not met until six months or beyond.
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Let’s define depersonalization and
differentiate it from derealization.
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Depersonalization is a persistent recurrent
experience of feeling detached from
as if one were an outside observer
of one’s mental process or body.
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For example, feeling as
though one were in a dream,
feeling as though they’re not in
reality or like time is moving slowly.
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Derealization is the
persistent or recurrent
experience of unreality
of the surroundings.
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For example, the world around the
individual is experienced as unreal,
dreamlike, distant or
distorted somehow.