Trauma: Symptoms, Diagnosis and Treatment

Mark Kamena, Ph.D.

markkamena@comcast.net

415-717-3447

2006 Forensic Mental Health Association Conference2006 Forensic Mental Health Association ConferenceA Time of Hope, A Time for VisionA Time of Hope, A Time for Vision

February 16, 2006February 16, 2006Seaside, CaliforniaSeaside, California

How The Brain Processes Threats (and what you can do about it)

I. Anatomy and Physiology of ThreatsII. Autonomic Nervous SystemIII. Psychological ResponsesIV. DiagnosesV. AssessmentVI. TreatmentVII. Residential Treatment Program for Emergency Responders

Brain Stuff• Every time you learn something or

acquire a new experience your brain's cells suffer a modification

• The brain exists in a delicate balance (homeostasis) where subtle changes may throw it into dysfunction ( Fever, Trauma and Delirium)

• Conditioned emotional response

One Way of Understanding the Brain

Physical Response

Limbic Brain External World / Internal Response.

Cortical Brain Conscious Thought / Action / Planning.

Reptilian Brain

Event

Stimulus

Reaction:

HorrorFearSadnessVulnerabilityAnger

Our fear reaction is a biological adaptation that evolved to help us surviveOur fear reaction is a biological adaptation that evolved to help us survive

Confusing Emotions

ANGER

“You triggered my automatic response system”

“You’re an

asshole”

Classical Conditioning

EventResponse

What happens to your body under stressful

conditions? – Another Perspective

Autonomic - primarily involuntary movements

1.Sympathetic – (Stress)

2.Parasympathetic (At Rest)

Heart, Lungs, and Circulation

• Heart rate and blood pressure increase instantaneously

• Blood flow may actually increase 300% to 400%

Heart, Lungs, and Circulation

• Spleen increases red blood cells into bloodstream to promote oxygen supply.

• As blood moves into muscles, blood vessels tighten causing vasoconstriction.

Immune System's Response

• Infection fighting systems (white blood cells, etc) are redistributed

• Immunity boosting agents are sent to the skin, bone marrow and lymph nodes

Mouth and Throat Response

•Fluids are diverted from nonessential locations, including the mouth

•Can make it difficult to talk.

Skin's Response

• Diverts blood flow away from the skin to support the heart and muscle tissues

• This causes cool, clammy, sweaty skin

Skin's Response

• Scalp also tightens so that the hair seems to stand up

Metabolic Response

•Stress shuts down digestive activity – a non essential activity

Physical Responses After The Event

• Fatigue

• Aches and pains

• Eating changes

• Gastrointestinal problems

Psychological and Emotional Responses

• Dissociation

• Denial Response

Normal Psychological Responses

During the Event

Normal Emotional Response:

• Frustration

• Anger

• Fear

• Sadness

• Numbness

• Guilt

Normal Emotional Response

• Helplessness

• Lack of Control

• Irritability

• Excitement

• Vulnerability

Normal Psychological Responses

After the Event

Sleep Disturbance and Nightmares

Normal Psychological Response

After the Event

• Sudden mood changes

• Anxiety

• Depression

• Anger

• Headaches

Normal but ProblematicPsychological Responses

• Withdrawal

• Sleep problems

• Anxiety / fear

Normal but ProblematicPsychological Responses

• Hyper-vigilance

• Aggressiveness

• Feeling out of control

• Survivor’s guilt

Problematic Responses to Traumatic Stress

• Family Fights

• Eating too much or too little

• Passivity or Aggression on the job

Problematic Responses to Traumatic Stress

Black / White thinking

• Alcohol and Drug Abuse

Normal Cognitive Response:

• Preoccupation with the event

• Second Guessing

• Poor Concentration

• Difficulty with problem solving

• Memory problems

Most Common Reactions

• Second Guessing

• Heightened Sense of Danger

• Legal Concerns

• Vulnerability

• Flashbacks

• Fearing Future Situations

Common Diagnoses

•PTSD

•Acute Stress Disorder

•Mood Disorder

•Anxiety Disorder

•Emergency Responder Exhaustion Syndrome

•DESNOS – Complex PTSD

•Substance-Related(in partial or full remission)

•Adjustment Disorder

•Eating Disorder

•Sleep Disorder

PTSD As We Knew It

DSM I – Gross Stress Reaction

DSM II – Adjustment Disorder

DSM III - PTSD

• Outside the realm of normal human experience

• Single stress incident

• Paradigm shift away from exacerbation of existing pathology

PTSD

• PTSD is a total person experience

• Symptoms effect– Mental Health– Physical Health– Family and Friends– Work– Spirit

PTSD

1. Must be exposed to a traumatic event

2. The event must be re-experienced by distressing recollections, dreams, flashbacks, etc.

3. Avoidance of locations, persons, etc

4. Persistent problems falling or staying asleep, irritability, Hyper-vigilant, etc.

PTSD – Diagnostic Criteria

Must be exposed to a traumatic event

Person's response to the event must involve intense fear, helplessness, or horror

The event must be re-experienced by distressing recollections,

dreams, flashbacks, etc.

Avoidance of locations, persons, etc

Sense of isolation

““No one else knows No one else knows what I am going what I am going through”through”

““I can’t burden other I can’t burden other people with this.”people with this.”

Persistent Problems With Increased Arousal

• Withdrawal

• Irritability

• Insomnia

• Hyper-vigilant

The symptoms are the body’s way of healing itself

DESNOS - Complex PTSD

• Childhood Trauma

• Cumulative

• Interpersonal

Some Common Factors

• Severity of the incident

• Nature of the trauma – interpersonal vs. natural disaster

• History of childhood sexual abuse or adversity

• Use of avoidance coping strategies.

• Vulnerability / Resiliency impaired

                    

                   

How to assess and/or diagnose PTSD?

The DAPS components are:

• Response Validity [16 items)

• Trauma specification [14 items]

• Immediate trauma impacts [14 items]

1. Peritraumatic Distress [8 items]

2. Peritraumatic Dissociation [6 items]• Posttraumatic response [35 items]

The DAPS components are:

• Posttraumatic response [35 items] – Reexperiencing [10 items]– Avoidance [10 items] – Hyperarousal [10 items]– Posttraumatic Impairment [5

items]

The DAPS components are:

• Supplementary scales [24 items]

– Trauma-specific Dissociation [4 items]

• Substance Abuse [10 items]

• Suicidality [10 items]

Cool Information … But What Does it Mean?

• A lot of how we react is beyond our control but does not mean we are weak or worthless.

• Now that you know what causes the symptoms what can you do about it?

Treatment Models

• Short Term vs. Long Term

• Cognitive Behavioral vs. Relational / Psychodynamic

• Utilizing the Best of Each

Medications

• Anti-Depressants

• Sleep

• Arousal / Anxiety

• Dissociation

EMDR

Relapse Prevention

• In Therapy

– Anticipation and Rehearsal

– Role Play

– Systematic Desensitization

– Relaxation

A Residential Program Example: West Coast Posttrauma Retreat

(WCPR)

• Involvement of the peers, clinicians and chaplains at WCPR is all pro-bono.

•The primary motivating factor for staff is a deep pride coupled with concern for the emergency service responder.

Primary Goals

• Keep the person alive / Do no harm

• Restore psychological and emotional functioning

• Reduction of physical symptoms

• Restore ability to participate in their own recovery

• Link client to appropriate resources

Goals Continued

• Discover any correlation between current critical incident reaction and prior developmental trauma.

• Help clients reinterpret the event more realistically.

• Psychoeducation

Education Goals

• Normalization – What they are experiencing are normal reactions to trauma

• Removing Self-Blame – They didn’t do anything wrong

• Clinician Credibility – Allows the client to know that you understand their situation

• Encourages Clients to Take Responsibility for their Treatment Outcomes

Residential Treatment

• Useful for emergency responders who have not benefited from traditional therapy.

• About 50% of the people who attend WCPR have never sought therapy.

• The goal after treatment is to re/connect clients to a therapist in their community.

• Police, fire, correctional officers and emergency services personnel are the typical residents.

• People affected by the CI for whom a debriefing or individual therapy has not been sufficient to reduce symptoms.

• About half of our clients are referred by their agency and half self-refer.

• Most clients come because they are in crisis and “not coming” was not an alternative.

Key Elements of the WCPR Residential Treatment Program

• Program must be of sufficient impact / relevance to effectively challenge long held faulty self-concepts

• Robust peer-support network• True residential treatment setting• VERY culturally competent mental health

professionals• A true collaboration which is peer driven and

clinically informed.

Treatment Objectives Continued

• Help the client accept themselves and their reactions realistically & uncritically.

• Help the client devise an 90 day action plan to achieve specific objectives in relationships, health, work, etc.

• Assist clients with obtaining mental health support in their community.

Peer Goals

1. Provide acceptance, validation and empowerment for the residents

2. Breaks the fallacy of uniqueness by demonstrating to clients that they are not alone and that what they are experiencing is normal

3. Help clients cope with the myth of invulnerability which has been shattered

Intrinsic Value of Peer Support

• Lisa A. Manzi’s 1995 study, “Evaluation of On-Site’s residential program.”

• “From the client’s informal accounts the real benefits of peer support go beyond these objectives and are things which cannot be measured, something deeper which involves empathy, friendship and companionship.”

Relapse Prevention at WCPR

• Developing a Plan

– Multi-component• Home/ Family/ Relationships• Health/ Medical/ Treatment • Work / Vocation• Spiritual• New Exposures

Relapse Prevention

– Specific• Measurable• Realistic• Observable

– Timeframe

– Accountability• Peers / Clinicians / Friends / Family

An Ounce of Prevention

The Chances of Saving an Individual's Career

Improve DramaticallyWith Early Intervention And

Treatment.

As Time Goes By,Our Work Changes From Saving

A Career ToSaving A LIFE!

Still Working85%

Service Pension3%

Medical3%

Stress3%

Returned to Work3%

Resigned3%

Resigned

Still Working

Service Pension

Medical

Stress

Returned to Work

Program Components• Initial Phone Intake• Intake – First, Worst

and Last, DAPS• 5 CISM Phases• Education Modules• Family/Relationship

Debriefings• Individual / Group• EMDR• Chaplain• AA • 90 Day Relapse

Prevention Plan• WCPR2001@aol.com

WCPR

“What is wrong with me that I can’t get better?”

“Will I will ever be the person I was, or the person I could have been.”

Common Questions asked

at WCPR