Post Traumatic Stress Disorder

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Post Traumatic Stress Disorder

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Title: Post Traumatic Stress Disorder

1
Post Traumatic Stress Disorder

Prevalence and Implications as a Co-morbid
Disorder

Developed by Mike Halligan LPC and Mike Hastie
LCSW for the DADS 2008 Conference,
Austin, Texas
2
Trauma Prevalence

Studies have shown that roughly half of persons
in inpatient mental health settings have
experienced physical or sexual abuse as children.
Some estimates are even higher. One urban mental
health center showed that 94 of its clients had
a history of trauma/abuse and that 42 of these
individuals had PTSD. But only a small fraction
of these persons (20) had received proper
treatment for the lasting effects of trauma.

3
The Hidden Diagnosis

When PTSD occurs with another mental illness, it
can make both illnesses much harder to diagnose
and treat. The symptoms of PTSD can mimic those
of schizophrenia, depression, and anxiety, among
others. When mental health providers fail to
screen patients for a history of abuse or trauma,
the provider may misdiagnose the problem and use
treatment that is inappropriate. If trauma is not
appropriately diagnosed and treated, treatment
for the mental illness is frequently ineffective.

4
What is PTSD? the DSM Diagnostic Criteria

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, or
a threat to the physical integrity of self or
others
(2) the persons response involved intense fear,
helplessness, or horror.
Note In children this may be expressed instead
by disorganized or agitated behavior.

The traumatic event is persistently
re-experienced in one (or more) of the following
ways
(1) 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 is
expressed.
(2) recurrent distressing dreams of the event.
Note In children, there may be frightening
dreams without recognizable content.
(3) 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 on awakening or when intoxicated).
Note In young children, trauma-specific
reenactment may occur.

(4) intense psychological distress at
exposure to internal or external cues
that symbolize or resemble an aspect
of the traumatic event or
(5) physiological reactivity on exposure
to internal or external cues that
symbolize or resemble an aspect of
the traumatic event

C. Persistent avoidance of stimuli associated
with the trauma and numbing of general
responsiveness (not present before the trauma),
as indicated by three (or more) of the following
(1) efforts to avoid thoughts, feelings, or
conversations associated with the trauma
(2) efforts to avoid activities, places, or
people that arouse recollections of the trauma
(3) inability to recall an important aspect of
the trauma

(4) markedly diminished interest or
participation in significant activities
(5) feeling of detachment or estrangement from
others
(6) restricted range of affect (e.g., unable to
have loving feelings) or
(7) sense of a foreshortened future (e.g., does
not expect to have a career, marriage, children,
or a normal life span)

D. Persistent symptoms of increased arousal (not
present before the trauma) as indicated by two
(or more) of the following
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance or
(5) exaggerated startle response

E. Duration of the disturbance (symptoms in
Criteria B, C and D) 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 duration of symptoms is lt 3 months
Chronic duration of symptoms is 3 months
With Delayed Onset if onset of symptoms is at
least 6 months after the stressor

11
The High Cost of PTSD

Persons with PTSD have the highest costs for
mental health care among persons with mental
illnesses. When untreated PTSD complicates
another mental illness, or prolonged, severe PTSD
leads to development of another mental illness,
the person often has high inpatient service
utilization, long lengths of stay, and may
eventually be seen as a treatment failure.
Research has shown that small percentages of such
patients account for large percentages of the
costs for care in public systems.

12
Co-occurring Disorders

A high prevalence of trauma exposure and PTSD
exists among the dually diagnosed.
55 of consumers and former consumers at a Maine
state hospital with a dual diagnosis of mental
illness and substance abuse report histories of
physical and/or sexual abuse.

13
Substance Abuse Trauma

In a sample of 100 male and female subjects
receiving treatment for substance abuse, more
than 1/3 were diagnosed with some form of a
dissociative disorder stemming from childhood
sexual or physical abuse.
Trauma alone is an important issue in increasing
the risk of alcohol abuse. When combined with
psychiatric disorders, risk significantly
increases.

Nearly 90 of alcoholic women were sexually
abused as children or suffered severe violence at
the hands of a parent.
71 to 90 of adolescent and teenage girls and
23 to 42 of adolescent and teenage boys in a
Maine inpatient substance abuse treatment program
reported histories of childhood sexual abuse.

15
Children Families

Among juvenile girls identified by the courts as
delinquent, more than 75 have been sexually
abused.
82 of all adolescents and children in continuing
care inpatient and intensive residential
treatment programs in Massachusetts have
histories of trauma as discovered in medical
records reviews.

16
Homelessness

92 of homeless mothers have experienced physical
and/or sexual assault.
70 of women living on the streets or in shelters
report abuse in childhood. Over 70 of the girls
on the street have run away from violence in
their homes.
79 of mentally ill homeless women have
experienced physical and/or sexual abuse. 87
experienced this abuse as children and as adults.

17
Mental Illness

50 to 90 of all adults and children are exposed
to trauma in their lifetimes. As many as 67 of
these individuals experience some lasting
psychological effects.
Approximately 50 of the people in inpatient
mental health settings have experienced physical
or sexual abuse as children.

One urban mental health center showed that
94 of its clients had a history of trauma
and 42 had PTSD.
One study of 275 mental health consumers, 98 had
a history of trauma. 43 suffered from PTSD.

The majority of adults diagnosed with Borderline
Personality Disorder (81) or dissociative
identity disorder (90) were sexually abused and
or physically abused as children.
Women who were molested as children are at four
times greater risk of Major Depression than those
with no such history. They are more prone to
develop bulimia and chronic PTSD.

20
Child Abuse

Childhood abuse can result in adult experiences
of shame, flashbacks, nightmares, severe anxiety,
depression, alcohol and drug use, feelings of
humiliation and unworthiness,
ugliness, and
profound terror.

Adults who were abused during childhood are
2 times greater chance to have at least one
lifetime psychiatric diagnosis.
3 times greater chance to have an affective
disorder.
3 times greater chance to have an anxiety
disorder.
2.5 times greater chance to have phobias

10 times greater chance to have a panic disorder
4 times greater chance to have an antisocial
personality disorder
There is a significant relationship between
childhood sexual abuse and various forms of
self-harm later in life, i.e.,
suicide attempts, cutting,
and self- starving.

For adults and adolescents with childhood abuse
histories, the risk of suicide increases 4 to 12
fold.
Most self injurers have a history of childhood
physical or sexual abuse. 40 of self-injurers
are men.

24
Child Abuse and Social Problems

More than 40 of women on welfare were sexually
abused as children.
Promiscuity and prostitution, have a correlation
with prior sexual abuse. 95 of woman engaging
in prostitution, pornographic movies, and nude
dancing were sexually assaulted as children.
Among juvenile girls identified as delinquent by
a court system, more than 75 were sexually
abused.

Women sexually abused during
childhood are 2.4 times more
likely to be re-victimized as
adults than women not sexually
abused.
Childhood abuse has a correlation with increased
adolescent and young adult truancy, running away,
homelessness, and risky sexual behavior.

26
Abuse and Sexual Violence

68 of women with a history of childhood incest
report incidents of rape or attempted rape after
the age of 14, compared to 38 of women in a
random sample.
Girls who experience violence in childhood are 3
to 4 times more likely to be victims of rape than
those who do not.
Twice as many women with a history of incest
become victims of domestic violence as women
without such a history.
95 of male serial killers were sodomized as
children.

Girls in high income families are more frequently
victims of incest than girls in lower-income
families.
38 percent of women report at least one
experience of incest or extra-familial sexual
abuse before age 18 28 report at lest one
experience before age 14. 16 were abused by a
relative and 4.5 by their fathers.
The United States has the highest rate of rape of
any country that publishes these statistics. 13
times higher than Great Britain and 20 times
higher than Japan.
The most frequent crimes against people with
disabilities, sexual offenses (90).
25 of infants one to six months are hit. That
figure raises by 50 of all infants by 6 months
to a year.

28
Abuse and Serious Medical Problems

Severe and prolonged childhood sexual abuse
causes damage to the brain structure, resulting
in impaired memory, dissociation, and symptoms of
PTSD.
Between 20 and 50 of abused children will
suffer mild to severe brain damage.
3 to 6 of all children will have some degree of
permanent disability as a result of abuse.

People who are abused as children may be more
prone to developing schizophrenia. A high rate
of physical and sexual abuse is reported among
children who were later diagnosed as
schizophrenic.
A particularly strong link exists between
childhood abuse and the hearing of voices.
Changes to the brain seen in abused children are
similar to those found in adults with
schizophrenia.

30
Stress and Brain Development

Stress sculpts the brain to
exhibit various antisocial,
though adaptive behaviors.
Whether in the form of
physical, emotional, or sexual
trauma and other forms, stress
can set off a ripple of hormonal changes and key
brain alterations that may be irreversible.

New brain imaging surveys and other techniques
show that physical, emotional, or sexual abuse in
childhood, (as well as stress in the form of
exposure to violence, warfare, famine, and
pestilence) can cause permanent damage to the
neural structure and function of the developing
brain itself.
These changes can permanently affect the way a
childs brain copes with the stress of daily
life, and can result in enduring problems such as
suicide, self-destructive behavior, depression,
anxiety, aggression, impulsiveness, delinquency,
hyperactivity, substance abuse, and conditions
such as Borderline Personality Disorder, volcanic
outbursts of anger, dissociative episodes,
hallucinations, illusions, psychosis, paranoia,
and impaired attention.

32
But you just need a pill

According to the National Mental Health
Association, American businesses, governments,
and families contribute 113 billion per year to
the cost of untreated and mistreated mental
illness. Between 50 and 75 of these untreated
and mistreated people have a history of trauma
that either caused or is contributing to their
mental illness. Based on the above figures, the
cost of untreated trauma is between
65,500,000,000 and 84, 750,000,000 per year.

33
Physical Abuse and Substance Abuse

The total cost of substance abuse and mental
illness per year is more than 300 billion. Of
this amount, 75 or 225 billion may be
attributable to unaddressed childhood trauma.

75 of adults in substance abuse treatment have a
history of childhood abuse and neglect. The cost
of unaddressed childhood trauma, based on public
health care costs related to substance abuse
treatment provided through Medicaid, is
582 million for addictive disorders
84 million for diseases attributable to
substance abuse.
Over 2 billion for disease for which substance
abuse is a risk factor.
252 billion for consumers with a secondary
diagnosis of substance abuse.
The total cost of substance abuse and mental
illness per year is more than 300 billion. Of
this amount, 75 or 225 billion may be
attributable to unaddressed childhood trauma.

35
EARLY CHILDHOOD TRAUMA EXPERIENCE COMMON
MENTAL HEALTH INSTITUTIONAL PRACTICES Unseen,
unheardAnnas Story

Annas abuse began at pre-verbal age. No one saw
the sexual trauma expressed in her childhood
artwork. No one saw the sexual trauma expressed
in her adult artwork with the exception of one
art therapist.
Anna's child psychiatrist did not inquire into or
see signs of sexual trauma. Anna was misdiagnosed
as Bipolar Disorder and Psychotic Disorder NOS.
Adult psychiatry sometimes does not inquire into,
see signs of or understand sexual trauma. The
appropriate diagnosis would have been PTSD with
dissociative features, and (later as an adult)
Borderline Personality Disorder secondary to
emotional, physical and sexual trauma coupled
with inadequate parent-child attachment.
Anna's attempts to tell parents, other adults,
were met with denial and silencing. Reports of
past and present abuse were ignored, disbelieved,
or discredited. Her behavior and out crys were
interpreted as delusional. Anna was silenced.
Two grade school psychologists did recognize the
signs of trauma, but heir insight was ignored by
Annas parents.

The priority of her parents was to protect self,
family relationships, and reputations.
Institutional secretiveness replicated the
family's secretiveness. Priority is to protect
institution, jobs, and reputations.
Emotional, physical or sexual abuse was not
reported up line neither as a child or after
admission to psychiatric treatment facilities,
and therefore public scrutiny not allowed.
In and out of institutions, perpetrator
retaliation if abuse was revealed was either
overtly threatened or perceived by the victim.
Patient or staff reporting of abuse may be
retaliated against by the institution or the
perpetrator.

37
Trapped

Annas abuse was not recognized and related to
Annas behavior, feelings and sexual trauma and
because no one had believed her except the school
psychologists discredited by her parents, Anna
was unable to escape the perpetrator's abuse.
Dependent as a child on her family caregivers,
and later on her inpatient care givers she was
unable to escape institutional abuse. She was
locked up, kept dependent and denied education
and skill development.

38
Trauma Informed Treatment

Care that is grounded in and directed by a
thorough understanding of the neurological,
biological, psychological and social effects of
trauma and violence on humans and is informed by
knowledge of the prevalence of these experiences
in persons who receive mental health services.
(NASMHPD, 2004)
Trauma-Informed care represents a change in
"mental models" - the underlying assumptions that
determine what we are able to think about.

Trauma Informed Treatment is not just a treatment
model , but also a philosophy that permeates
every aspect of the treatment environment, and
every staff member in a treatment system from the
janitor up to the Chief Operating Officer.
Trauma Informed Treatment prioritizes safety,
informed treatment, collaborative treatment
process and individual choice in the treatment
process.
The continuing story of Anna illustrates the
damage that can be done when a treatment system
is not sensitive to or understanding of the
debilitating effects of trauma that can last a
life time.

40
Replicating the Original Sexual Trauma

A male staff member, who unwittingly or
uncaringly re-enacted the trauma perpetrated by
Annas abuser pulled her T-shirt over her head,
and stripped off clothing when she was secluded
or restrained, often by or in presence of male
attendants.
Anna experienced this as being stripped by the
abuser "with nothing on below. To inject her
with medication when she was behaviorally out of
control, the patient's pants were pulled down
exposing buttocks and thighs, often by male
attendants.
She was held down, arms and hands bound with
"restraints" her arms and legs were shackled to
a bed.
The Abuser "blindfolded me with my little
T-shirt. Cloth would be thrown over Anna's face
if she spat or screamed while strapped down in
restraints.

41
Isolated

The Abuser "opened my legs. Anna was forced
into a four-point restraint in spread-eagle
position. The abuser "was examining and
putting things in me. Medication was injected
into her body against her will. Boundaries
violated. Exposed. No privacy. No privacy from
patients or staff. No boundaries. Each of these
actions re-enacted previous trauma and
strengthened her sense of helplessness and
hopelessness.
When out of control behaviorally, Anna was taken
by her perceived abuser to places hidden from
others. She would be forced, often by male
attendants, into seclusion room. Occasionally
she was raped or suffered other sexual trauma.
Isolated in her experience "Why just me?
Separated from community in locked facilities. "I
thought I was the only one in the world. The
staff or parents never had any recognition of
patients' sexual abuse experiences or how they
might have dealt differently with her as a sexual
trauma survivor.

42
Blamed and Shamed

Thus, on a regular basis, Anna was forced to
relive her original sexual trauma keeping her in
the cycle of hypervigilent terror, unable to
benefit from treatment, and still misunderstood
by staff.
I had "this feeling that I was bad...a bad seed.
Patients stigmatized as deficient, mentally ill,
worthless.
Abusive institutional practices and ugly
environments convey low regard for patients, tear
down self-worth. She became the "difficult to
handle" child. She became a "non-compliant,"
"treatment-resistant" difficult-to-handle
patient.
She was blamed, spanked, confined to her room for
her anger, screams and cries. Her rage, terror,
screams and cries were often punished by meds,
restraints, loss of "privileges" and seclusion.
So not only did she have to continually relive
her trauma, the unintentional negative
reinforcement also continued.

43
Unprotected

Anna was defenseless against the perpetrators
abuse.
Her attempts to tell went unheard. There was no
safe place for her even in her own home or room.
Mental patients are defenseless against staff
abuse. Reports disbelieved. No safeguards
effectively protect patients. Personnel policies
prevent dismissal of abusive staff.

44
Crazy-Making

Appropriate anger at sexual abuse was seen as
something wrong with Anna. Abuse
continued--unseen.
Appropriate anger at abusive institutional
practices were judged pathological and met with
the continuation of those practices.
Anna's fear from threat of being abused was not
understood. The abuse continued--unseen.
Fear of abusive and threatening institutional
behavior is labeled "paranoia" by the institution
producing it.
Sexual abuse continued unseen or silenced.
Psychiatric denial of sexual abuse. Message to
patient "You did not experience what you
experienced."

45
Betrayed Annas experience

Anna was violated by trusted caretakers and
relatives.
Disciplinary interventions were "for her own
good. Anna was re-traumatized by helping
professional/psychiatry interventions presented
as "for the good of the patient.
Family relationships were fragmented by
separation, divorce. Anna had no one to trust and
depend on. She learned that relationships of
trust get arbitrarily disrupted based on needs of
system. No continuity of care.
These types of life events/experiences create a
sense of distrust of self and others at the
deepest level of psychic defensive functioning,
and are often the root of personality and
anti-social disorders.

46
What if?

Anas parents had believed her and sought
professional treatment for her at her first
outcry?
What if Ana had been treated in a Trauma Informed
System, where the MH workers, therapists,
nursing and psychiatric staff all worked together
to create an environment where sensitivity to
trauma and safety were the top priorities in
treatment planning and intervention.

47
The Outcome (in process)

Luckily, Anna began working with a new Therapist
at the Institution, who saw her projective
drawings as expressions of pain, betrayal, fear,
anxiety etc. primarily resulting from her sexual
trauma and all the mistaken inappropriate
responses to her trauma-driven behavior as
stepping stones to developing a debilitating
personality disorder.

Today, Ana is 43 years old and lives in a a group
half-way house for women with similar
trauma-based disorders.
Thanks to appropriate diagnosis by her new
therapist, she is no longer
subject to invasive medical interventions or
treatments, or
further sexual trauma. Her trauma is validated
and
treated appropriately, and she has pressed
charges
against the male staff who perpetrated further
sexual
violence against her.
She participates in individual and group therapy
using
the Dialectical Behavior Therapy Model which has
been
Shown to be the most appropriate evidence-based
treatment for her condition.
Ana was sexually, emotionally and physically
traumatized from the time she was two years old
until she was in her late 30s. She still has a
long rough road to recovery and learning to have
appropriate relationships and how to manage her
PTSD symptoms, but shes now getting the
appropriate treatment to meet her needs. Shes
slowly putting her psyche and ego back together.