HABEAS CORPUS RESOURCE CENTER

PRACTICE GUIDE

TRAUMA AND

POST-TRAUMATIC STRESS DISORDER

DAWN COSTA

KYONG YI

Habeas Corpus Resource Center

50 FREMONT STREET, SUITE 1800

SAN FRANCISCO, CALIFORNIA 94105

(415) 348-3800

APRIL 2001


Trauma and Post-Traumatic Stress Disorder:

An Outline

  1. PTSD General Description/Intro
  1. What is Trauma
  1. Immediate Responses to Trauma
  1. Types of Trauma
  2. Combat/War
  3. Community Violence
  4. Sexual abuse

a)  Male sexual abuse

b)  Female sexual abuse

  1. Physical abuse

a)  Child abuse (including neglect)

b)  Domestic violence

c)  Witness to domestic violence

  1. Chronic violence (‘Living in Captivity’)
  1. PTSD Diagnosis
  1. Symptoms
  2. Hyperarousal / Hypervigilance
  3. Dissociation
  1. Neurobiological Changes (limbic systems, CNS changes, critical periods, attachment, memory, etc.)
  2. Emotional
  3. Behavioral
  4. Cognitive
  5. Physiological/biochemical
  1. Clinical Implication
  2. age/developmental stage of trauma
  3. intensity and frequency
  4. proximity
  5. degree of perceived life threat
  6. lack of caretaker / social support
  1. Additional Factors
  2. Alcohol and drug abuse
  3. Gender Differences
  4. Dual Diagnosis

a)  Mood disorders (especially depression)

b)  Other anxiety disorders

c)  Organic mental disorders (e.g., memory loss)

  1. DSM Criteria
  2. Current - DSM IV and DSM IV TR(complex PTSD?)
  3. Historical

a)  DSM III-R

b)  DSM III

c)  Stress Response Syndrome

  1. Instruments of Assessment
  2. PDI-R (Psychiatric Diagnostic Interview – Revised)
  1. Difference between ASPD
  1. PTSD Investigation
  1. How to Conduct Interviews
  1. Gathering and Reading Records (what to look for)
  1. Legal Claims
  1. Standard of Care
  2. Competency
  3. Guilt
  4. Penalty


Trauma and Post-Traumatic Stress Disorder:

An Overview

Posttraumatic Stress Disorder (PTSD) is a combination of psychological and physiological disturbances developed in response to traumatic event(s). While the clinical diagnosis of PTSD is fairly new, accounts illustrating the profound effects of trauma date centuries back. There has been a long tradition of psychoanalytic exploration of trauma, beginning with Freud’s observations that a splitting of consciousness appeared to occur in hysterical patients who reported a history of childhood sexual trauma. In the 19th century, ‘Railway Spine’ described victims of railway accidents who expressed somatic complaints despite any sign of physical injury. Throughout World War I, traumatized soldiers were diagnosed with “Shell Shock” syndrome, a condition stemming from soldiers’ effort at self-preservation. In World War II, similar combat related symptoms were labeled “War Neurosis” or “Combat Fatigue”. In the 1970s, the traumatic effects of rape and domestic violence were acknowledged and identified as ‘rape trauma syndrome’ and ‘battered women’s syndrome’.

In 1980, The American Psychiatric Association added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III). The construction of PTSD occurred in large part as a by-product of the Vietnam War. The diagnostic criteria encompassed a cluster of symptoms prevalent among combat survivors. Over the following decades, a tremendous body of research and clinical assessment has illuminated both clinical and laymen understanding of the nature of trauma and its pervasive impact on human functioning. Although a controversial diagnosis when first introduced, PTSD has filled an important gap in psychiatric theory and practice. The concept that the etiology of mental illness can be an external force (i.e., traumatic event) substantiated the significant role of the environment in both the origin and manifestation of mental disorder.

WHAT IS TRAUMA?

The key to understanding the scientific basis and clinical expression of PTSD is the concept of “trauma”. (Posttraumatic Stress Disorder: An Overview, Matthew J. Friedman, MD, Ph.D., Executive Director, National Center for PTSD)

The definition of trauma has evolved throughout the years. Initial attempts to qualify the nature of traumatic stress limited evaluations to the characteristics of the trigger event. However, individual variations seen in response to identical stressors quickly challenged classifications that were derived solely from external variables.

Trauma results from the interaction of the external stimuli and internal perception. The varieties of experiences known to cause trauma are immense. There are however two general characteristics fundamental to all trauma experiences.

1.  Presence of traumatic stimulus: Traumatic events involve an actual or perceived threat to life or severe physical harm or injury. The threat can be physically or psychologically terrifying. Traumatic responses are not limited to personal attacks. Witnessing or learning of incidents of violence or death can be equally traumatic, especially when the witness knows and cares for the victim.

2.  The stimulus elicits feelings of terror, helplessness, loss of control, and devastation: In response to a traumatic stressor, the person experiences an overpowering sense of terror that manifests in feelings of helplessness and devastation. Trauma consumes all levels of human function and overwhelms the individual’s ability to cope.

Trauma can result from powerful one-time incidents or repetitive prolonged stress. The subjectivity of individual perception makes it virtually impossible to provide a comprehensive list of traumatic events. Instances of traumatic events include:

§  Natural disasters

§  Rape

§  Assault

§  Combat

§  Community violence

§  Physical abuse (domestic violence and child abuse)

§  Sexual abuse (adult and child)

§  Political / human rights abuse

§  Accidents (e.g. car, airplane, fires)

RESPONSES TO TRAUMA

People who have endured horrible events suffer predictable psychological harm. In the face of trauma, the victim is rendered helpless and terrified. Traumatic events overwhelm the body’s thought and response systems, altering the person’s perception of himself/herself and the world. Emotional, behavioral, cognitive, social, and physical aspects of functioning are impaired. The process by which fear turns to trauma; trauma produces response; and responses manifest into disorder depends upon the presence and interaction of numerous factors including:

1.  Severity of stressor

2.  Biological factors

3.  Age (developmental level)

4.  Social context (e.g. family, community, socioeconomic status, etc)

5.  Previous and subsequent life events

Immediate reactions to trauma formulate the basis of future perception, interpretation, and response to stress. In this respect, symptoms can be seen as adaptations of normal coping mechanisms, which can linger indefinitely and reappear in various contexts. Posttraumatic Stress Disorder symptoms fall into three categories:

§  Hyperarousal

§  Intrusion

§  Avoidance

Hyperarousal

In the face of danger people predictably attempt to defend themselves from the impending harm. Symptoms of hyperarousal are characteristic of the body’s natural ‘fight or flight’ defense mechanism. The sympathetic nervous system, the body’s emergency response system, takes over. The activation of the central nervous system causes significant increases in heart rate, blood pressure, respiration, muscle tension, and adrenaline. The person becomes hypervigilant, focusing almost entirely on the traumatic event or a component of the event. All non-critical information is tuned out. The body remains on permanent alert following the trauma as physiological arousal continues unabated. The traumatized person lives in constant fear and anticipation of danger. They are hypersensitive to any reminders of the traumatic event. Exposure to external or internal stimuli associated with the traumatic event may immediately reactivate the body’s alarm system with the same intensity of the initial episode. Repeat encounters with the same stimulus do not desensitize the person. The person often reacts to each encounter as if it is the first.

Symptoms of Hyperarousal:

§  Intense psychological distress and/or physiological reaction when exposed to external or internal stimuli that symbolize or resemble an aspect of the traumatic event

§  Sudden sweating, heart palpitations, shortness of breath or chest pains

§  Difficulty concentrating and making decisions

§  Sleep problems – difficulty falling or staying asleep

§  Changes in appetite

§  Hypervigilance - frequently feeling on guard

§  Reacting to small provocations

§  Easily startled and jumpy

§  Feeling extremely protective of loved ones and fearful for their safety

§  Psychosomatic complaints – physical ailments caused by increased physical arousal such as gastrointestinal problems (i.e. ulcers), headaches, high blood pressure, menstrual problems, back aches, stomach aches, and allergies

§  Increased anxiety

§  Sudden tears, anger or panic

Intrusions

A person suffering from PTSD often relives the traumatic experience through intense recurring nightmares and vivid intrusive images. They can appear at any time and with little provocation. Once the memory is triggered, the person may experience a flashback to the traumatic incident, losing all awareness of the present moment. Traumatic memories differ from normal memories of events that are processed and assimilated into our ongoing life story. Memories of traumatic events are stored as sensations and images that remain static. The person may be unable to think about the trauma without triggering feelings, smells, images, and sounds associated with the experience. Small, insignificant reminders are enough to relive the event. Intrusive symptoms are often so debilitating they can cause a person to withdraw from their normal life.

Symptoms of Intrusions:

§  Recurrent flashbacks/hallucinations – recollection of images and physiological sensations

§  Acting or feeling as if the experience is happening in the present

§  Intrusive play (in children)

§  Recurrent distressing dreams of event

§  Intense distress from reliving trauma

§  Risk-taking behavior - may place themselves in a similar situation, sometimes in disguise

Avoidance

Avoidant behavior, also known as constriction, emotional numbing, or dissociation, emerges as a means of self-protection. During the traumatic event a person may become detached and numb. Dissociation is a trance-like state in which perceptions, emotions, and sense of body and time are altered. Victims often describe feeling as if they are observing the event from outside their body. The person dissociates or becomes numb when confronted with traumatic memories and in some cases, will dissociate in response to any stressful stimuli.

A person suffering from PTSD often actively avoids any reminders of the traumatic event including places, people, thoughts, or activities. In an attempt to create some sense of safety and control anxiety, traumatized people often restrict their lives and withdraw from social interaction.

Symptoms of Avoidance:

§  Feelings of indifference, emotional detachment, passivity

§  Suddenly ‘tuning-out’

§  Isolation

§  Restricted range of feelings

§  Diminished interest in everyday activity

§  Inability to recall aspects of trauma

§  Efforts to avoid thoughts, feelings, place, people, and activities associated with trauma

§  Alcohol or drug use to induce numbing

LONG-TERM EFFECTS OF TRAUMA

The responses to trauma are best understood as a spectrum of conditions rather than as a single disorder. They range from a brief stress reaction that gets better by itself and never qualifies for a diagnosis, to classic or simple post-traumatic disorder, to the complex syndrome of prolonged, repeated trauma. (Herman, Judith (1992). Trauma and Recovery, pp. 119)

Symptoms of PTSD are often difficult to identify because people who have been traumatized display extreme and fluctuating emotions. They often oscillate between states of being hyperaroused or extremely overwhelmed by memories of the trauma to states of extreme disconnection. Outside the context of the traumatic event, the behavioral manifestations of these symptoms can be easily misinterpreted. The impact of trauma on an individual’s feelings, thoughts and reactions may be ingrained into the person’s perception of the world and can appear as personality traits rather than an adaptive traumatic response. Recognizing PTSD is further complicated by the fact that symptoms can appear long after the traumatic event. The most crucial component to accurately diagnosing PTSD is a COMPREHENSIVE SOCIAL HISTORY.

Symptoms Associated with PTSD:

§  Depression

§  Substance Abuse

§  Eating disorders

§  Low self-esteem

§  Panic disorders

§  Chronic physical complaints

§  Suicidal tendencies

§  Self-mutilation

§  Little regard from one’s own safety or the safety of others

§  Feelings of shame and guilt

§  Lack of meaning in the world

§  Unable to form meaningful relationships

§  Unable to find meaningful work

§  Poor academic performance

§  Paranoia - sees the world as unsafe and has difficulty trusting others

§  Deficiencies in organized thinking/decision making

§  Regressed or delayed development in children

§  Increased need to control everyday experiences

§  Sense of foreshortened future

PTSD is often misdiagnosed as:

§  Antisocial Personality Disorder / Conduct Disorder (in children)

§  Major depression

§  Attention Deficit Disorder with Hyperactivity (ADHD)

§  Specific Phobias

Chronic Trauma

The dynamics of ongoing and persistent trauma exposure have proven to intensify and prolong symptoms of PTSD. Physical and sexual abuse are the common examples of chronic trauma. Abusive environments mimic conditions of the torture and coercive control described by prisoners of war. Domestic captivity entraps children and partners (in most cases woman) in a world of pervasive terror, unpredictable violence, and social isolation. The conflict between fear of the perpetrator and natural desire to gain their love and acceptance exacerbates feelings of confusion, betrayal and helplessness.

Neurobiological Impact

The body releases various hormones and neurochemicals in response to traumatic stress. Chronic exposure to trauma causes increase levels or dysregulation of neurochemicals which in turn alter brain chemistry and functioning. These alterations influence how information is processed and stored in memory. Studies have found significant neurobiological abnormalities related to PTSD including:

§  Increased levels of catecholomines (i.e. norephinephrine) in the brainstem – the brainstem plays a key role in the interpretation of sensory information and activation of stress response. Chronic trauma can cause an increase in baseline levels of catecholomines in the brainstem, which may result in a continuous state of hyperarousal. The cortex regions of the brain responsible for information processing are disengaged. Persistent arousal has also been linked to:

Ø  Underdevelopment or atrophy of the hippocampus – critical for learning and processing memory.

Ø  Limbic system dysfunction – critical for storage, integration, and retrieval of memory

Ø  Abnormalities in the left hemisphere – affects memory and verbal abilities

§  Increased levels of endogenous opiates – associated with emotional numbing; interferes with memory consolidation process.

§  Decrease levels of serotonin – related to decrease in ability to regulate emotional arousal. Numerous studies have found a correlation between reduced levels of serotonin and increase impulsivity and aggression

§  Decrease brain volume associated with childhood trauma