Post Traumatic Stress Disorder
Barbara C. Fisher, Ph.D.

Brain changes with PTSD
Hyperarousal state of PTSD leads to disrupted adrenal gland mechanisms (Tobin, 2001)
Onset of dementia heralded by increased PTSD symptoms (vanAchterberg et.al., 2001)
Brain abnormalities occur with chronic or complicated PTSD (Bonne, et.al. 2001)
Response to previously experienced threatening events significantly determines the psychological and somatic response to subsequent stress (Morgan, et.al. 2001)
History of trauma predisposes the person to more symptoms of dissociation with increased or stress occurring later in their lives
Increased CNS noradrenergic (norepinephrine) activity seen in chronic PTSD (Geraciot et.al. 2001)
Presence of sub-threshold PTSD symptoms significantly raises the risk for suicidal ideation (Marshall et.al., 2001)
Neuropsychological Effects of Stress
Memory is poor, however eventually they can recall the information
Distractibility is a major issue
The pattern seen on testing is distinctly different from the pattern of Head Injury, Tumor, Seizure Disorder, and Stroke
Clinically tends to be subtle (not greater than one standard deviation difference between potential and performance)
Consequences of PTSD
Thinking difficulties
Difficulty communicating
Cannot sustain attention or concentration
Relationship problems
Personality/emotional changes
Confused Thinking due to Over-Reactivity
Information is not received correctly
Mis-interpret things and situations
Cannot see situation as it truly is
The perception of events or statements is incorrect or “off”-things are judged incorrectly
They assign incorrect meanings to events
There is an exaggeration of circumstances
Prediction of negative and the worst happening
Communication Difficulties
Problems with output expression: written or oral: – Word retrieval: Cannot find word-while looking for word-they forgot what they wanted to say
No connection to significant people or people in general: no hook to people-if upset they turn off and walk away: clinically seen with PTSD and/or frontal injury – Often appear as oppositional, defiant, conduct disorder or anti-social personality disorder
Stress increases all of the above
Selective Attention Issues
Cannot selectively attend to some stimuli and not other stimuli = attend to everything in the environment – This results in the tendency to wander all over the room, they cannot sit still – Continual movement-staying with task for maximum of two seconds before attracted to another novel stimuli – Cannot inhibit or stop tendency to respond to everything novel in environment
Children do not listen-they easily ignore adult correction – Mis-labeled ODD, conduct disorder, ADHD
Emotional Distance
Lack of emotional connection to anyone – Lot of work to establish connection – Very demanding of others in significant relationships
Issues of not trusting anyone to be there to depend upon or for help
Lack of connection leads to being non- responsive to adult discipline or feedback from relationships
Moments of dis-connection when recovering from trauma and/or re-experiencing trauma
Coping with Trauma
Tucking away internally
Creating safe world in their mind
Keeping people walled off
No one able to touch the person emotionally
Above symptoms occur at time of trauma and shortly following trauma or at the time of the re-living of trauma
If no safe person or environment is established-this pattern is present all of the time
PTSD has Global Impact
Leads to a decline in physical health- increased physical vulnerability, hypothesis of lowered immune system response
Negatively affects emotional health leading to lack of trust in future relationships
Negatively impacts academic functioning if in school or job performance
Classic Signs/Symptoms of PTSD
Emotional flatness, numbing: lack of affect, faraway look
Confusion, poor sustained attention
Hyper-alertness and overly serious
Exaggerated Startle Reflex, stress symptoms
Appear to withdraw and become more internal or more agitated and emotional as presenting externally seen symptoms
Sleep Problems
Complaints of sleep are universal, fragmented sleep
The inability to sleep as well as difficulty initiating and maintaining sleep
Anxiety arousals are common in PTSD
REM and non-REM nightmares
Repetitive nightmares are common
Nightmares often represent a "re-living" of the original trauma and associated emotions
Conditioned fear toward sleep and accompanying avoidance behaviors may develop, especially if the original trauma occurred in the sleep setting
Nightmares
To warrant a diagnosis of nightmare the diagnostic manual requires that 4 criteria be met:
  1. A sudden awakening from sleep with intense fear, anxiety, and a feeling of impending harm.
  2. Immediate recall of frightening dream content.
  3. Full alertness on awakening with little confusion or disorientation.
  4. A delayed return to sleep, or the episode occurs in the last half of the night.
The distinctive features of a nightmare are the recall of a long, frightening dream and clear orientation on awakening – Nightmares are common in young children and peak at ages 3 to 6 years (Leung and Robson 1993) – The general agreement is that the frequency of nightmares decreases with age and with an increasing sense of competence (Salvio et al 1992) – For some people nightmares remain a lifelong chronic problem. Hartmann claims that 3% of the population have 1 or more attack per week (Hartmann 1984)
Frequent nightmares were found exclusively in those (15%) with a current diagnosis of Post Traumatic Stress Disorder. – Fifty-seven percent of the variance in nightmare frequency was accounted for by war exposure and a current posttraumatic stress disorder diagnosis (Neylan et al 1998).
Whether the setting of the nightmare is in the past or present, those of post-traumatic stress disorder patients are typically threatening in nature. (Esposito et al 1999).
PTSD Symptoms: Physical
Hippocampus: the central coordinator of the stress response
PTSD symptoms:
Poorer Prognosis for Aging
Difficulty adjusting to change or transition
Changes in brain results in increased physical fragility
Lifelong disturbed sleep patterns do not allow brain to rest and recover
Diminished ability to age gracefully
Long Term Emotional Consequences of PTSD
Brittle, emotionally reactive
Inability to handle adversity
Very low frustration tolerance
Difficulty learning-no tolerance for failure
Live only in the moment
Helplessness/lack of control approach to life
Little trust in self or in others
Negative expectations-prepare and expect the worst
Long Term Consequences Affecting the Forming of Relationships seen with PTSD
Emotionally reactive and labile-everything bothers them, low frustration tolerance
Attachment problems-cannot get close to others-remain un-attached
Need relationship control = Compulsive, care- giving and taking care of others to control the relationship
Defensive Separation: clinging behavior cannot separate from parent or figure most attached to – Excessive Dependency: cannot separate for independent development
Prognosis
In posttraumatic stress disorder more than one-third of patients remain symptomatic after many years (Kessler et al 1995)
Extremely young or old patients tend to have a worse prognosis than those with rapid onset, short duration, and good pre-morbid function, who have no history of substance abuse
Generalized anxiety is often a life-long condition, with only 38% demonstrating full remission after 5 years (Yonkers et al 2000)
Co-morbid depression, anxiety disorders, and substance abuse are common in PTSD


Introduction  Synopsis  Discussion  Research

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