Trauma

• Originally either a direct physical blow to the body

• Or the resulting damage

• A surgeon’s concept

Psychological Trauma

• Metaphorical extension of the medical term to the mind

• Events were traumatic in virtue of their meaning, not in virtue of their physical dimensions

Side note

• Exposure to photographs or media presentations of atrocities constitutes secondary source of risk(Nader et al., 1993)

Some Possible Problems in Studying Trauma

• Blaming the victim– Identifying risk factors does not entail blaming

victims– Causal versus moral discourse

• Harmfulness vs. wrongfulness– Merely because something is morally wrong

does not mean that it produces psychiatric disease

– Abusive behavior can be condemned on grounds other than harmfulness

Discussion/Exercise

• Do you think young children should be involved in trauma research?

The question of “bias”

• Having an opinion does not count as “bias” -- as long as it is warranted by the evidence

• Bias – Selective reporting of the data– Misreading it– Using different evaluative standards

• When someone makes a clinical (or other claim), we must ask “How do you know?”

• What are the arguments?

• What is the evidence?

Or,..

• “Show me the data!”

Early childhood trauma studies

• Had to overcome scientific and social reluctance to engage children directly

• Collective evidence about heightened level of children’s – mental activity during and after trauma– Complexity of traumatic experiences– Seriousness of resultant distress

• Attention to children witnessing extreme violenceIncluding parental suicide, parental homicide, rape

• Questions about reliability of children’s eyewitness accounts and suggestibility– Spurred efforts to understand processes of memory, learning,

co-construction of traumatic narrative

Consequences of Trauma

CTS and PTSD

Acute traumatic event Chronic traumatic situation

Interpersonal violence

Act of nature beyond control

School Shooting Terrorist attachRape, Mugging

Physical and Sexual abuseBullying, War

Natural disasterLoss of loved one

Sever accident

Serious illnessSerious injury

Dearth, Drought

Types of Trauma

• Type 1 versus Type 2 Trauma (Lenore Terr, 1991)– Type 1: acute, unforeseeable, singular (e.g.,

automobile accident, hostage-taking)– Type 2: repeatedly, to some extend

predictable (e.g., chronic sexual assault, living in war zone)

Consequences of Trauma

• Young children’s psychological response to Type 1 traumatic events has long been considered relatively mild (Garmezy & Rutter, 1985)

• However, now clear: Trauma can have dramatic impact on development of children– Including young children

Trauma and Development

• Children react to traumatic experiences in ways that reflect the developmental tasks they are confronting

• 6-year-olds exposure to violence/ trauma associated with decrements in IQ and reading achievement (Delaney-Black et al., 2002)

• Similar results for child abuse related to– delayed language– cognitive development– low IQ– poor school performance(Veltman & Browne, 2001)

Consequences on normal developmental path

• Violence affects child’s sense of personal safety, predictability, and protection– Even when not objectively threatened

(Groves et al., 1993)

• Children struggling intense fears/concerns about caregiver– often unable to achieve normal dev. milstones– fall behind in emotional, social, cognitive growth– Poorer physical health

(Osofsky, 1999)

Some studies

• Project Head Start: 160 children exposed to violence and maltreatment– more prone to poor physical health

(Graham-Bermann & Seng, 2005)

• Longitudinal research– Traumatic childhood experiences impair mental and

physical health into adulthood

• Childhood trauma and adversity as a major risk factor for many serious adult mental and physical health problems (Edwards et al., 2003)

Trauma and Psychopathology

• Traumatic experiences increase risk of range of psychopathological outcomes

• Adverse Childhood Experiences (ACEs) Study (Edwards et al., 2003)– Alcoholism, drug abuse, suicide attempts, smoking,

poor general health, poor mental health, severe obesity, sexual promiscuity, sexually transmitted disease

• Trauma effects on health-risk behaviors, such as smoking/physical inactivity– Multiple health problems (heart disease, cancer, liver

disease (Felitti et al., 1998)

Trauma and emotion regulation

• Early exposure to sever interpersonal violence (and other forms of trauma) can decrease capacity for emotional regulation(Cheasty, Claire & Collins, 2002)

• Developmental studies indicate that child abuse disturbs the acquisition of appropriate emotion regulation and interpersonal skills(Cloitre et al., 2005)

Trauma and the brain

• Traumatic experiences such as sexual abuse affect dev. of brain and impair major hormonal systems (Teicher et al.,

2003) • Affected brain areas associated

– with regulation of emotion– Control of impulses and reasoning– Problem solving(DeBellis et al., 2002)

• Dysregulation of major hormonal systems– Hypothalamic-pituitary-adrenal (HPA) axis– Crucial biological role in buffering the physical effects of stress(DeBellis et al, 1999)

• Sympathetic nervous system can become hyperactive leading to increased arousal and hypervigilance (DeBellis et al. 1997)

Academic performance and IQ

• Abused/neglected children exhibit poorer performance in school(Vetlman & Browne, 2001)

• Studies show effects on– IQ scores– Language– School performance (Shonk & Cicchetti, 2001)

• Maltreated children impaired in– Attention task– Abstract reasoning– Executive functioning (Beers & DeBellis, 2002)

Academic performance and IQ

• Population-based sample of 1,000 twin pairs found– Exposure to domestic violence accounted for approx.

4% of variation in IQ– Associated with average decrease of 8 points(Koenen et al., 2003)

• Administrative database for 7,940 children receiving Aid to FDC– Child maltreatment system involvement predictive of

entry into special education (Honson-Reid et al., 2004)

Children in foster care and child welfare programs

• Have multiple experiences of community and family violence (Stein et al., 2001)

• Parents often also have a trauma history– toddlers and preschoolers who witnessed domestic violence:

mothers on average experienced 13 traumatic events (range from 8-23)

– 40% had been physically abused, in addition to domestic violence

– Many others sexually abused, placed in foster homes, exposed to neighborhood/community violence

(Lieberman et al., 2005) • Head Start participants

– Maternal distress symptoms even more important than community violence exposure (Aisenberg, 2001)

CTS and PTSD

• Child Traumatic Stress (CTS)– National Child Traumatic Stress Network

www.nctsnet.org • Posttraumatic stress disorder (PTSD)

– Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) www.dsmivtr.org

• American Psychiatric Association• PTSD as part of anxiety disorders

– International Classification of Diseases, 10th version (ICD-10) www.who.int/classifications/icd/en

• World Health Organization• F00-F91 Mental and behavioral disorders• PTSD: neurotic, stress-related and somatoform disorders

Child Traumatic Stress (CTS)

• is a psychological reaction that children and adolescents, who are exposed to traumatic events or traumatic situations, have when this exposure overwhelms their ability to cope with what they have experienced(NCTSN, 2006)

• a traumatic experience results from a discrepancy between the experience of a threatening situation and the individual resources to cope with this situation, and is accompanied by feelings of helplessness and being unprotected, leading to an enduring concussion of conceptions of the self and the view of the world – (Fischer & Riedesser, 2003)

CTS reactions

• Not every child experiences CTS after experiencing a traumatic event, but those who do developed reactions that linger and affect their daily lives long after the traumatic event has ended.

• reactions consist of distressing cognitions and emotions, along with strong frightening physical reactions, broadly classified in three different groups:– intrusive thoughts, images, flashbacks and nightmares related to

the traumatic experiences– avoidance of persons, situations, places associated with the

traumatic experiences– physical hyper arousal, attention deficits and sleeping problems(NCTSN, 2006)

Posttraumatic stress disorder

• Depending on the kind of traumatic experience a considerable proportion of children and adolescents develop psychiatric conditions such as posttraumatic stress disorder (PTSD).

• In fact PTSD is one of the most common psychological disorders in childhood and adolescents (Landolt, 2004)

• but PTSD is a formal psychiatric diagnosis that is made when specific criteria about the number, duration, and intensity of symptoms are met– CTS is not a formal diagnosis but describes a range of a child’s

or adolescent’s distressing reactions to trauma (NCTSN, 2006)

Psychological Trauma Historical background

• Ancient and mediaeval times– Since 2000 B.C., Homer ‘Illias’, Achilles’ (similar to symptoms of

PTSD)– Cultural artifacts

• American Civil war– ‘irritable heart’, ‘soldier’s heart’, ‘effort syndrome’, Da-Costa-

Syndrome (DaCosta, 1871)– Weakness, gastrointestinal symptoms, breathlessness, sleeping

problems, dizziness – Oppenheimer (1889) ‘Trauma’ (Psychiatry)

• Disasters and accident– Railroad Spine Syndrome (John Ericksen, 1867)– Anxiety, memory problems, poor concentration, sleep problems,

night mares, somatic symptoms

Psychological Trauma Historical background

• Pierre Janet, Jean-Martin Charcot, Sigmund Freud– Trauma and Hysteria, Hypnoses– Childhood trauma causes hysteria/neuroses

(Ferenczi)

– Masud Khan/John Bowlby (1976) ‘cumulative trauma’

• WW I+II– ‘Shell shock’ (Charles S Myers, 1915)– Pre-existing psychopathology and psychological

healthy– Moral issues

Studies on childhood Trauma in WW I+II

• Bodman (1941)– 8,000 British children 5-14 years– 8% psychological symptom (nightmares, war-related anxiety,

bodily reactions to reminders, avoidant and aggressive behavior

• Mercer & Despert (1943)– Poor concentration, school problems

• Bradner (1943)– Symptoms even 1-year post-war

• Carey-Tefzer (1949)– 1,203 British school children– 12.6% psychological symptoms– Memory problems, sleep problems

Psychological Trauma Historical background

• Concentration camps– 50-60% of Jewish children symptoms (Friedman, 1948)– ‘survivor syndrome’ (Dressing & Berger, 1991)– Sever biological, psychological, social and existential

consequences• reduced ability to cope with future psychological/biological stressors

• Disasters– Messina Earthquake (Eduard Stierlin, 1911), 25% symptoms– Boston ‘Coconut Grove Fire’ (Adler, 1943)– Vicksburg Tornado (Bloch, Silber & Perry, 1956)

• First study with children

Posttraumatic Stress Disorder (PTSD)

• 1952 first mentioned in classification of APA• But not in DSM-II, prevailing psychiatric opinion:

– stress reactions emerged during action– dissipated shortly after removed from battlefield– Unless preexisting mental problems or vulnerabilities

• American involvement in the Vietnam War– Early psychiatric optimism: Low rates of mental

problems in-country relative to previous American wars (Borus, 1974)

– “Post-Vietnam Syndrome” (Lifton & Shatan)

“Post-Vietnam Syndrome”:Its signs and symptoms

• Guilt about having committed atrocities

• Survival guilt

• Emotional numbing

• Nightmares

• Anger against “The Establishment”

“Post-Vietnam Syndrome”

• Chronic– (Consistent with some reports appearing in the mid-

1960s on chronic stress reactions in World War II veterans)

• Delayed onset – Problems emerged months and years after the vet

returned from the war

Robert Spitzer and DSM-III

• Diagnostic and Statistical Manual of Mental Disorders - Third Edition

• Appeared in 1980

• Revolutionized psychiatry– Explicit descriptive diagnostic criteria– Aimed to be reliable– Atheoretical regarding etiology (causes)

DSM-III

• Lifton, Shatan, and their allies sought to have a Post-Vietnam Disorder included

• Would enable veterans to obtain service-connected disability payments and psychiatric services if problems could be attributed to the war

Objections

• Run counter to orthodox military psychiatry opinion on combat stress reaction

• Reluctance to have a mental disorder defined in reference to a historical event

• The symptoms covered by combinations of other disorders anyway

• A political artifact of the anti-war movement

How did PTSD make it into the DSM-III?

• Lifton and associates made common cause with other doctors working with trauma survivors– Rape trauma syndrome– Concentration camp syndrome– Natural disasters (Buffalo Creek)

Ironies of Inclusion

• Originally, advocates of the new diagnosis advanced the argument of uniqueness– The Vietnam War represented a unique set of

stressors– Produced a unique Post-Vietnam Syndrome

• Dropped “Vietnam” from name

• And claimed that ANY traumatic stressor can produce a characteristic profile of signs and symptoms

• From uniqueness to a universal psychobiological syndrome

• Ignored vulnerability factors

• Appealed to Nancy Andreasen, M.D., Ph.D.

• Her burn patients exhibited similar psychological problems

• Posttraumatic stress disorder (PTSD) appeared in 1980

• “It is rare to find a psychiatric diagnosis that anyone likes to have, but PTSD seems to be one of them” (Andreasen, 1995)

DSM-III Aims

• To establish reliable criteria for diagnosing mental disorders– Validity presupposes reliability– Explicit criteria

• Definitions of disorders should be descriptive and avoid reference to etiology– If clinicians -- psychoanalytic, biological, behavioral -- cannot

agree on what causes mental disorders, at least they can agree on how to describe and diagnose them

• The diagnosis of PTSD violated these guidelines– Reliability not (then) established– Many symptoms overlapped with those of other disorders– And a causal factor -- exposure to traumatic stressor -- was

integral to the definition of the disorder

Discussion

• Why do you think PTSD might be a psychiatric diagnosis anyone likes to have?

Criterion A: Exposure to a traumatic stressor

• Outside the bounds of everyday experience

• Combat, rape, confinement to a concentration camp

• To produce stress symptoms in nearly everyone

Exposure to a traumatic stressor

• Deemphasis on personal vulnerabilities

• The stressor was to “blame” for the illness

• Is PTSD a “normal response to an abnormal stressor”?

• Or is it a disorder (disease, illness, syndrome) and therefore “abnormal”?

• Shall we say that a woman psychologically suffering after a violent rape has the “brain disease” of PTSD?

• Or is her response fully natural and expectable, given what she has endured?

• Are we stigmatizing her by saying that she is “disordered”?

• But consider someone who is hit by a car and whose leg is broken

• Surely the broken leg is a “normal response to an abnormal stressor”

• But does that mean that the person should not be diagnosed and treated?

B Criteria: Reexperiencing symptoms

• Recurrent and intrusive recollections of the event

• Recurrent dreams of the event

• Sudden acting or feeling as if the traumatic event were reoccurring, because of an association with an environmental or ideational stimulus (“flashback”)

C criteria: Numbing

• Markedly diminished interest in one or more significant activities

• Feelings of detachment or estrangement from others

• Constricted affect

D criteria: Miscellaneous

• Hyperalertness or exaggerated startle response

• Sleep disturbance

• Guilt about surviving when others have not, or about behavior required for survival

D criteria: Miscellaneous (cont.)

• Memory impairment or trouble concentrating

• Avoidance of activities that arouse recollection of the traumatic event

• Intensification of symptoms by exposure to events that symbolize or resemble the traumatic event

Duration and subtypes

• PTSD (Acute)– Onset of symptoms within six months– Duration of symptoms less than six months

Duration and subtypes

• PTSD (chronic or delayed)– Onset of symptoms at least six months after

the trauma– Duration of symptoms six months or longer

• One of the chief rationales for PTSD was making room for delayed onset PTSD

• But ever since PTSD appeared in the nosology, so-called delayed PTSD has seemingly vanished from the landscape of psychiatry

PTSD in DSM-IV (1994)

• Criterion A: “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”

• “fear, helplessness, or horror”

• Criterion A1: One no longer need be either the direct recipient of trauma or its direct witness

• Criterion A2: One’s emotional reaction to the event as part of the event?

• A1 events without A2 reaction rarely cause PTSD

PTSD in DSM-IV (1994)

• C criteria– Avoidance grouped with numbing– Inability to recall an important aspect of the

trauma– Sense of a foreshortened future

PTSD in DSM-IV (1994)

• Other changes– Guilt gone– Memory problems gone (but concentration problems

remain)– Duration of symptoms must be at least one month– Acute versus chronic cutoff: 3 months– Criterion F: clinically significant impairment or distress

PTSD in children

• Depending on the age of the children specific nature of symptoms can vary– young children often show overly anxious, regressive

behavior (e.g. bedwetting or baby talk) and physical and/or emotional hyper arousal,

– school-age children report many intrusive thoughts and images fear of repetitions or thoughts of revenge. Some school-age children also show ambivalent and/or restless behaviors and sleeping problems.

(Landolt, 2004)

PTSD in children

– Adolescents, struggle over their realization of regressive behaviors and report feeling isolated and left alone in their suffering. Adolescents are also often upset about the lack of support the parents, school or society at large was able to provide in the traumatic situation

(Landolt, 2004)

Measures of PTSD

• UCLA Child PTSD Reaction Index (Frederick, Pynoos & Nader, 1992)– Degree, subscales, not diagnosis

• Clinician-Administered PTSD Scale (Naderer et al., 2002)– 8-18 years, diagnosis

• Other measures– Impact of events scale (Horowitz, 1976)

• For adults, not with young children Children’s PTSD Inventory (Saigh et al., 2000)

– Trauma Symptom Checklist (Briere, 1996)– CHILD PTSD Symptom Scale (Foa et al., 2001)

CPTSD-RI

• Clinical practice and research

• Good for exploration of subtypes and degree

• handout