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Trauma- and Stressor-Related Disorders

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Title: Trauma- and Stressor-Related Disorders


1
Trauma- and Stressor-Related Disorders
  • University of Manoa
  • Anna Weihl, Christine Keanu, Genevieve Parks,
    Patricia Kaleiwahea

2
Trauma- and Stressor- Related Disorders
  • This chapter includes disorders in which exposure
    to a traumatic or stressful event is listed
    explicitly as a diagnostic criterion.
  • These include
  • Adjustment Disorders
  • Reactive Attachment Disorder
  • Disinhibited Social Engagement Disorder
  • Other specified Trauma- and Stressor-Related
    Disorder
  • Unspecified Trauma- and Stressor-Related Disorder
  • Posttraumatic Stress Disorder
  • Acute Stress Disorder
  • we will mainly be talking about these two
    disorders tonight

3
Overview of the Diagnostic Category of Trauma-
and Stressor-Related Disorders
  • Adjustment Disorders
  • Diagnostic Criteria
  • A. The development of emotional or behavioral
    symptoms in response to an identifiable
    stressor(s) occurring within 3 months of the
    onset of the stressor(s)
  • B. These symptoms or behaviors are clinically
    significant, as evidenced by one or both of the
    following
  • 1. Marked distress that is out of proportion to
    the severity or intensity of the stressor, taking
    into account the external context and the
    cultural factors that might influence symptom
    severity and presentation.
  • 2. Significant impairment in social,
    occupational, or other important areas of
    functioning.
  • C. The stress-related disturbance does not meet
    the criteria for another mental disorder and is
    not merely and exacerbation of a preexisting
    mental disorder
  • D. The symptoms do not represent normal
    bereavement
  • E. Once the stressor or its consequences have
    terminated, the symptoms do not persist for more
    than an additional 6 months

4
Overview of the Diagnostic Category of Trauma-
and Stressor-Related Disorders
  • Diagnostic Features
  • Prevalence
  • Development and Course
  • Risk and Prognostic Factors
  • Culture-Related Diagnostic Issues
  • Functional Consequences of Adjustment Disorders
  • Differential Diagnosis
  • Comorbidity

5
Overview of the Diagnostic Category of Trauma-
and Stressor-Related Disorders
  • Other specified Trauma- and Stressor-Related
    Disorder (page 289)
  • Symptoms are characteristic of a trauma- and
    stressor-related disorder, but do not meet the
    full criteria for any of the trauma- and
    stressor-related disorders diagnostic class.
  • This diagnose used in situations in which the
    clinician chooses to record other specified
    trauma- and stressor-related disorder followed
    by specific reason. (e.g., persistent complex
    bereavement disorder.)
  • Unspecified Trauma- and Stressor-Related Disorder
    (page 290)
  • Same as above except clinician chooses not to
    specify the reason the criteria are not met due
    to insufficient information to make specific
    diagnose. (e.g., in emergency room settings.)

Anna
6
Overview of the Diagnostic Category of Trauma-
and Stressor-Related Disorders
  • Reactive Attachment Disorder (page 265)
  • Reactive Attachment Disorder (RAD) 313.89
  • Characterized by a pattern of markedly disturbed
    and developmentally inappropriate attachment
    behaviors, in which a child rarely or minimally
    turns preferentially to an attachment figure for
    comfort, support, protection, and nurturance.
  • The essential feature is absent or grossly
    underdeveloped attachment between child and
    putative caregiving adults.
  • Children with RAD are believed to have the
    capacity to form selective attachments. However,
    because of limited opportunities during early
    development, they fail to show the behavioral
    manifestations of selective attachments (i.e.
    when distressed they show no consistent effort to
    obtain comfort, support, nurturance, or
    protection from caregivers and they do not
    respond more than minimally to comforting efforts
    of caregivers).
  • RAD is associated with the absence of expected
    comfort seeking and response to comforting
    behaviors.
  • Child with RAD emotion regulation capacity is
    compromised, and they display episodes of
    negative emotions of fear, sadness, or
    irritability that are not readily explained.
  • A diagnosis of RAD should not be made in children
    who are developmentally unable to form selective
    attachments. Thus the child must have a
    developmental age of at least 9 months.

7
Overview of the Diagnostic Category of Trauma-
and Stressor-Related Disorders
  • Reactive Attachment Disorder Continued(page 265)
  • The prevalence of RAD is unknown but relatively
    rarely seen in clinical settings. RAD is often
    found in young children exposed to severe neglect
    before being placed in foster care. However,
    even in this population the disorder is uncommon
    and occurs in less than 10 of those children.
  • There is no standard treatment for RAD, however
    it often includes Individual counseling,
    education of parents and caregivers about the
    condition, parenting skills classes, family
    therapy, medication for other conditions that
    may be present (such as depression, anxiety,
    etc.), special education services, and
    residential or inpatient treatment for children
    with more-serious problems or who put themselves
    or others at risk of harm.
  • There are some controversial treatment practices
    that should be noted as they can be
    psychologically and physically damaging and have
    led to accidental deaths. These practices
    include re-parenting/re-birthing/holding
    therapy, tightly wrapping, binding or holding
    children, withholding food or water, forcing
    child to eat or drink, and yelling, tickling or
    pulling limbs, triggering anger that finally
    leads to submission.
  • Heres a video clip on holding therapy
    http//www.youtube.com/watch?vOdWhcyz6KbY

8
Overview of the Diagnostic Category of Trauma-
and Stressor-Related Disorders
  • Disinhibited Social Engagement Disorder
  • Diagnostic Criteria
  • A. A pattern of behavior in which a child
    actively approaches and interacts with unfamiliar
    adults and exhibits at least two of the
    following
  • 1. Reduced or absent reticence in approaching
    and interacting with unfamiliar adults
  • 2. Overly familiar verbal or physical behavior
  • 3. Diminished or absent checking back with adult
    caregiver after venturing away, even in
    unfamiliar settings
  • 4. Willingness to go off with an unfamiliar
    adult with minimal or no hesitation
  • B. The behaviors in Criterion A are not limited
    to impulsivity (as in attention-deficit/hyperactiv
    ity disorder) but include socially disinhibited
    behavior
  • C. The child has experienced a pattern of
    extremes of insufficient care as evidenced by at
    least one of the following

9
Overview of the Diagnostic Category of Trauma-
and Stressor-Related Disorders
  • 1. Social neglect or deprivation in the form of
    persistent lack of having basic emotional needs
    for comfort, stimulation, and affection met by
    caregiving adults
  • 2. Repeated changes of primary caregivers that
    limit opportunities to form stable attachments
  • 3. Rearing in unusual settings that severely
    limit opportunities to form selective attachments
  • D. The care in Criterion C is presumed to be
    responsible for the disturbed behavior in
    Criterion A
  • E. The child has a developmental age of at least
    9 months
  • Specify
  • Persistent- the disorder has been present for
    more than 12 months
  • Current severity Disinhibited social engagement
    disorder is specified as severe when the child
    exhibits all symptoms of the disorder, with each
    symptom manifesting at relatively high levels

10
Overview of the Diagnostic Category of Trauma-
and Stressor-Related Disorders
  • Diagnostic Features
  • Associated Features Supporting Diagnosis
  • Prevalence
  • Development and Course
  • Risk and Prognostic Factors
  • Functional
  • Differential Diagnosis
  • Comorbidity

11
Descriptions for Acute Stress Disorder
  • Diagnostic Criteria
  • A.) Client must have been exposed to actual
    threatened death, serious injury, or sexual
    violation in one (or more) of the following ways
  • 1.) directly experiencing the traumatic event(s)
  • 2.) witnessing, in person, the event(s) as it
    occurred to others
  • 3.) learning that the event(s) occurred to a
    close family member or close friend.
  • 4.) experiencing repeated or extreme exposure to
    aversive details of the traumatic event(s).
  • B.) Also, there must be the presence of nine (or
    more) of the following symptoms from any of the
    five categories of intrusion, negative mood,
    dissociation, avoidance, and arousal, beginning
    or worsening after the traumatic event(s)
    occurred. (there are 14 symptoms listed in the
    nine categories)
  • Specifiers None listed

    Coding and recording
    procedures None listed

12
Descriptions for Acute Stress Disorder,
continued.
  • Diagnostic Features
  • development of characteristic symptoms lasting
    from 3 days to 1 month following exposure to one
    or more traumatic events, (traumatic event
    examples are listed, some stressful events do not
    possess the severe and traumatic components, but
    may lead to adjustment disorder diagnose
    instead),
  • typically involves an anxiety response that
    includes some re-experiencing or reactivity of
    traumatic event (e.g., strong emotional,
    physiological, anger, or aggressive responses at
    traumatic reminder).
  • Witnessing or learning of traumatic events are
    limited to close relatives or close friends,
    which must have been violent or accidental
    (listed is some examples of witnessed/learning
    events)
  • Traumatic event being re-experienced, intrusive
    memories (various ways listed)
  • Distressing dreams
  • Flashbacks
  • Psychological distress or physiological
    reactivity

13
Descriptions for Acute Stress Disorder,
continued.
  • Diagnostic Features continued
  • Depersonalization, de-realization (detached sense
    of oneself, in a daze)
  • Avoidance of trauma stimuli (refuse to discuss
    trauma, excessive alcohol use at mention of
    trauma, avoiding interacting if reminds of
    trauma)
  • Sleep onset and maintenance (nightmares)
  • Quick temper with little provocation,
    irritability
  • Concentration difficulties, memory difficulties,
    staying focused difficulties
  • Jumpiness, heightened startle response
  • Panic attacks, chaotic or impulsive behavior
    (children may display separation anxiety)
  • Associated Features Supporting Diagnosis
  • Catastrophic or extremely negative thoughts about
    heir role in traumatic event, or to the event
    itself or future likelihood of harm
  • Acute grief reactions or post-concussive symptoms

14
Descriptions for Acute Stress Disorder,
continued.
  • Prevalence
  • Varies according to the nature of the event and
    the context in which it is assessed.
  • Development and course
  • Cannot be diagnosed until 3 days after a
    traumatic event
  • May or may not progress to PTSD after 1 month
    (half who develop PTSD initially presented Acute
    Stress Disorder)
  • Symptoms can worsen during the initial month
  • Re-experiencing can vary across development,
    (children can report differently than adults)
  • Functional Consequences
  • Impaired functioning in social, interpersonal or
    occupational, also sleep, energy levels and
    capacity to attend to tasks.
  • Avoidance, withdraw, and nonattendance.

15
Descriptions for Acute Stress Disorder,
continued.
  • Risk and Prognostic Factors
  • Temperamental- having prior mental health, higher
    levels of negativity affectivity, greater
    perceived severity of traumatic event(s),
    avoidance coping style, and/or having
    catastrophic appraisals of the traumatic event
    are strong predictors of acute stress disorder.
  • Environmental- if been exposed to traumatic
    event(s), and/or has an history of prior
    trauma(s), greater chances of developing acute
    stress disorder.
  • Genetic and Physiological- Females are at
    greater risk, and/or elevated reactivity before
    trauma(s) is another predictor of an increased
    risk of developing acute stress disorder after a
    trauma.
  • Culture-Related Diagnostic Issues
  • Varies cross-culturally, particularly with
    respect to dissociative symptoms, nightmares,
    avoidance, and somatic symptoms.

16
  • Gender-Related Diagnostic Issues
  • More prevalent in females than males, maybe due
    to sex-linked neurobiological differences in
    stress response, or the likelihood of possibility
    of exposure to high conditional risk trauma(s)
    (e.g., rape, other interpersonal violence)
  • Differential Diagnosis
  • Adjustment disorders diagnose given when
    criteria doesnt meet acute stress disorders
    Diagnostic Criteria A.)
  • Panic disorder although common in acute
    disorder, panic disorder is diagnosed only if
    panic attacks are unexpected, there is anxiety
    about future attacks, or there are maladaptive
    changes in behavior associated with fear of dire
    consequences of the attacks.
  • Dissociative disorder in absence of
    characteristics of acute stress disorder, severe
    dissociative responses can be diagnosed as
    de-realization/depersonalization disorder, or if
    severe amnesia, dissociative amnesia may be
    indicated.
  • Posttraumatic stress disorder if symptoms
    persist more than 1 month and meet criteria for
    PTSD, (acute stress must occur 1 month after
    trauma, and resolve with-in that 1 month period),
    criteria is then changed from acute stress to
    PTSD.

17
  • Differential Diagnosis continued.
  • Obsessive-compulsive disorder recurrent
    intrusive thoughts, but not related to an
    experienced traumatic event, compulsions are
    usually present, and other symptoms of acute
    stress disorder are typically present.
  • Psychotic disorder flashbacks must be
    distinguished from illusions, hallucinations, or
    other perceptual disturbances, which may occur in
    schizophrenia, other psychotic disorders,
    depressive or bipolar disorder w/ psychotic
    features, a delirium, substance/medication-induced
    disorders, and psychotic disorders due to
    another medical condition. Flash are
    distinguished by being directly related to
    traumatic experience and by occurring in the
    absence of other psychotic or substance-induced
    features.
  • Traumatic brain injury (TBI) symptoms for a
    brain injury from traumatic event(s), and
    symptoms previously termed post-concussive can
    overlap with symptoms of acute stress disorder,
    however re-experiencing and avoidance are
    characteristics of acute stress disorder where as
    persistent disorientation and confusion are more
    specific to TBI. Also, symptoms of acute stress
    disorder persist for up to only 1 month following
    trauma exposure.

18
Acute Stress Disorder/YouTube Video
  • http//www.youtube.com/watch?vAl1A0t1vWzk
  • (1 minute, 55 seconds)

19
EBP for Acute Stress Disorder??
  • Psychotherapeutic Interventions
  • Cognitive behavior therapy
  • Patient utilization of existing support network
  • Psychological debriefing
  • Single-session therapy
  • Eye movement desensitization and reprocessing
    (EMDR)
  • Reactive eye dilation desensitization and
    reprocessing (REDDR)
  • Hypnotherapy
  • Desensitization
  • Relaxation exercises
  • Internet based therapies
  • Stress inoculation
  • Imagery rehearsal
  • Prolonged exposure techniques
  • Case management
  • Group therapies including present-centered and
    trauma-focused group therapies
  • Optimism training
  • Goal setting and achievement
  • Biofeedback
  • Multiple channel exposure therapy
  • Assertiveness training
  • Outward Bound group recreational therapies
  • http//www.nrepp.samhsa.gov/

20
Eye Movement Desensitization and Reprocessing
(EMDR)
  • Eye Movement Desensitization and Reprocessing
    (EMDR) is said to be an effective
    psychotherapeutic approach for treatment of
    traumatic memories.
  • It is an empirically supported integrative
    psychotherapeutic approach for treatment of
    Post-Traumatic Stress Disorder (PTSD) (Van der
    Hart, Nijenhuis, Solomon, 2010). It is not only
    used to treat Post-Traumatic Stress Disorder but
    any other disturbing event that the individual
    finds him-self unable to move through in a
    healthy way.
  • EMDR involves a neurobiological process that
    helps the individual reprocess a traumatic or
    disturbing event into an experience that can be
    remembered without pain (Shapiro, Forrest,
    2004).
  • One of the goals and objectives in treatment is
    to use EMDR to resolve disturbing events
    (trauma), the identification and utilization of
    resources, and for future scripting.
  • Basically, by processing negative cognitions
    through EMDR, an increased ability to
    self-regulate emotional responses is seen.
  • http//www.youtube.com/watch?vKpRQvcW2kUM

21
4 Literature Reviews on the EBP EMDR for ASD
  • 1.) Kutz, et. al, 2008, found that a single
    session of modi?ed and abridged protocol of EMDR
    was found to provide complete relief for 50 and
    substantial relief for another 27 of acutely
    stressed patients, most of whom had been exposed
    to an isolated traumatic event. While the
    standard EMDR protocol is geared as a
    comprehensive approach for chronic patients with
    multiple accumulating issues, this single-session
    abridged protocol was effective for focused
    symptom relief in the early phases.
  • 2.) The American Journal of Psychiatry, et. al,
    2004, compared EMDR with no treatment, cognitive
    behavior therapy, exposure approaches (not
    involving in vivo exposure), variants of EMDR
    (e.g., dismantling studies), and nonspecific
    treatments. EMDR was more effective than no
    treatment and comparable to other active
    treatments.

22
4 Literature Reviews on the EBP EMDR for ASD
continued
  • 3.) An article in the Wiley Inter Science
    Journal, 2009, found that symptom reduction has
    been shown to be comparable over treatment with
    EMDR and the 6-month follow-up, EMDR had the
    superior outcome. In studies that had diagnosis
    as an outcome measure, between 77 and 90 of
    EMDR patients no longer met diagnostic criteria
    for PTSD at the end of treatment.
  • 4.) Researchers found that only trauma-focused
    CBT and EMDR produced significant clinical
    improvements, and no major differences were found
    between the two in head-to-head comparison
    studies (Kennedy, et. al., 2007).

23
Posttraumatic Stress Disorder YouTube Video
  • http//www.bing.com/videos/search?qGeorgeCarlin
    PtsdFormVQFRVPviewdetailmid9B6B008519D3B7220
    36E9B6B008519D3B722036E

24
PTSD ETIOLOGY/CRITERIA
  • PTSD is an anxiety disorder that develops in
    response to
  • Exposure to actual or threatened death, serious
    injury, or sexual violence by directly
    experiencing, witnessing the event, learning that
    the traumatic event happened to a close family
    member or friend, and experiencing repeated
    exposure
  • THOSE AT-RISK INCLUDE
  • People who have been in a natural disaster, such
    as a tidal wave, earthquake, tornado or tsunami.
  • Anyone who have been raped or physically or
    sexually abused.
  • Anyone who have witnessed or been a part of a
    life-threatening event.
  • Anyone with military combat experience or even
    civilians who have been injured in war.

25
PTSD ETIOLOGY/CRITERIA
  • Presence of one (or more) of the following
    symptoms associated with the traumatic events,
    beginning after the traumatic event(s) occurred
  • Re-experiencing the event involuntarily through
    distressing memories(flashbacks)
  • Re-experiencing nightmares or distressing dreams
    in which it is related to traumatic event.
  • Dissociative reactions(flashbacks) where
    individual feels or acts as if the traumatic
    event was recurring.
  • Intense or prolonged psychological distress at
    exposure to internal or external cues that
    symbolize or resemble an aspect of the traumatic
    event(s)
  • Marked physiological reactions such as Numbness,
    Insomnia, Lack of concentration.

26
PTSD ETIOLOGY/CRITERIA
  • Persistent avoidance of stimuli associated with
    the traumatic event(s)
  • Avoiding people, places, conversations, etc. that
    arouse distressing memories of traumatic event.
  • Avoiding distressing memories, thoughts, or
    feelings about or associated with the traumatic
    event.
  • Negative alterations in cognitions and mood
    associated with the traumatic event(s), beginning
    or worsening after the traumatic event(s)
    occurred.
  • Marked alterations in arousal and reactivity
    associated with the traumatic event.
  • Duration of the disturbance is more than 1 month.
  • Disturbance causes clinically significant
    distress or impairment in relationships with
    parents, siblings, peers, or other caregivers.
  • Disturbance is not attributable to the
    physiological effects of a substance(medication
    or alcohol) or another medical condition.

27
Prevalence
  • Projected lifetime risk of PTSD rates higher
    among veterans as well as police, firefighters,
    emergency medical personnel (jobs high risk)
  • Projected lifetime risk for PTSD at age 75 years
    is 8.7(U.S.)
  • Twelve-month prevalence among U.S. adults is 3.5
  • Europe and most Asian, African, and Latin
    American countries have lower estimates of
    .5-1.0
  • Highest rates are found among survivors of rape,
    military combat, and ethnically or politically
    motivated internment and genocide.

28
Development and course
  • Any age (beginning after the 1st year of life)
  • Symptoms begin approximately 3 months after
    traumatic event
  • Abundant evidence for what DSM-IV called
    delayed onset now called delayed expression
    which is a delay in meeting full criteria
  • ½ of adults will experience complete recovery
    within 3 months
  • Symptoms for some lasts more than 12 month and
    for others more than 50 years

29
Functional Consequences
  • PTSD ASSOCIATED WITH
  • High levels of social, occupational, and physical
    disability
  • Considerable economic costs
  • Impaired functioning across social,
    interpersonal, developmental, educational,
    physical health, and occupational domains
  • Poor social and family relationships, work
    absences, lower income, lower educational and
    occupational success.
  • High levels of medical utilization

30
Evidence Based Practices Pharmacotherapy
  • Post-Traumatic Stress Disorder in Women
  • SSRIs (Selective serotonin reuptake
    inhibitor)remain a first-line pharmacotherapy for
    PTSD, although mood stabilizers, newer
    antidepressants, atypical antipsychotics and
    adrenergic agents have some evidence for
    efficacy. SSRIs were the first class of
    psychotropic drugs discovered and are the most
    widely prescribed antidepressants in many
    countries.
  • CBT, although randomized, comparative studies do
    not provide evidence for superiority of one
    intervention over another
  • Exposure therapy and cognitive processing have
    been demonstrated to work well in women with PTSD
    following adult victimization or childhood abuse.

31
Evidence Based Practices Pharmacotherapy
  • CURRENT STATUS OF PHARMACOTHERAPY FOR PTSD
  • AN EFFECT SIZE ANALYSIS OF CONTROLLED STUDIES
  • Findings suggested that serotonergic
    antidepressants for the treatment of PTSD are
    effective and of a relative advantage
  • Effective medications for conditions
    characterized by pervasive anxiety, intrusive
    thoughts, and avoidance (PTSD) may have strong
    but extreme selectivity for blocking reuptake of
    serotonin over norepinephrine.
  • Serotonergic agents for treatment of PTSD is
    encouraged

32
Evidence Based Practices CBT EMDR
  • A Community-Based study of EMDR and Prolonged
    Exposure
  • Pilot study which compared prolonged exposure and
    EMDR
  • 22 patients from a university based clinic
    serving rape and crime victims
  • Results showed that both approaches produced
    significant reduction in PTSD and depression
    symptoms
  • Success was faster with EMDR with 7 of 10 of the
    participants having 70 reduction in PTSD
    symptoms as compared to PE which was 2 of 10
  • EMDR better tolerated by participants thus having
    lower drop out rate
  • However patients who remained in PE had reduction
    of PTSD scores as well
  • Results of this study suggest that both PE and
    EMDR equally effective in reducing symptoms of
    PTSD and depression

33
Evidence Based Practices CBT Prolonged Exposure
  • Treatment choice for PTSD
  • Study on 273 women with varying degrees of trauma
    history and subsequent PTSD symptoms.
  • All participants were given the same sexual
    assault scenario and three treatment options to
    choose from which included Sertraline(SER),
    prolonged exposure(PE), or no treatment.
    Question if this happened to you, what would you
    do
  • Treatment choice, reaction to treatment options,
    and treatment credibility were examined.
  • Women were more likely to choose PE for treatment
    of chronic PTSD.

34
Description for Culture Women
  • Overview Forging Research Priorities for
    Womens Mental Health
  • By Nancy Felipe Russo
  • Prevalence Rates
  • - Frequencies and patterns of mental disorder
    are vastly different for women and men.
  • - The NIMH Epidemiological Catchment Area
    Program found that there are substantial
    gender differences in prevalence rates of
    lifetime diagnoses (a) women clearly
    predominate in diagnoses of major depressive
    episodes, agoraphobia, and simple phobia,
    whereas men predominate in antisocial
    personality disorder and alcohol
    abuse/dependence (b) women are more likely
    than men to have received a diagnosis of
    dysthymia, obsessive-compulsive,
    schizophrenia, somatization disorder, and
    panic disorder and (c) no gender differences
    in manic episode or cognitive impairment.

35
Description for Culture Women
  • Utilization Rates
  • - There are marked differences between men and
    women in the utilization of mental health
    services, differences that vary with type of
    facility.
  • - For inpatient facilities, women make up a
    greater proportion of admissions than men in
    nonfederal general hospitals and private mental
    hospitals men predominate in admission to
    state and county mental hospitals and Veterans
    Administration hospitals.
  • - For outpatient facilities, female clients
    predominate.
  • Diagnosis Related to Gender, Marital Status and
    Ethnicity
  • - There are gender differences in diagnosis
    that vary by marital status and race/ethnicity
    and that cannot be explained by biomedical
    models.
  • - The relationships among gender, marital
    status, and psychological disorder depends on
    the psychological disorder and vary with
    ethnicity.

36
Description for Culture Women
  • Overview Forging Research Priorities for
    Womens Mental Health
  • By Nancy Felipe Russo
  • Diagnosis and Service Delivery
  • - Patterns of mental disorder vary markedly
    for men and women whether data from community
    surveys or from patient populations are used.
  • - According to community surveys, women
    predominantly are diagnosed with the more
    severe forms of psychiatric disorders but
    according to service delivery research, men
    predominate in the more intensive community
    treatment settings (residential and partial
    care vs. outpatient). The question remains does
    this represent a desirable outcome of treating
    females in less restrictive settings or does
    it show that females are underserved.

37
Description for Culture Women
  • Overview Forging Research Priorities for
    Womens Mental Health
  • By Nancy Felipe Russo
  • Multiple Roles and Womens Mental Health
  • - Women typically have multiple roles that
    they are fulfilling (mother, wife, employee,
    etc.) and this can affect their mental health.
  • - Parenting is one caretaking role that
    affects women more than men. According to
    McBride (1988), parenthood, particularly when
    children are young, increases the symptoms of
    psychological distress for women whether or not
    they work outside the home and the symptoms
    appear to increase with the number of children
    living in the home.

38
Description for Culture Women
  • Prevalence of Civilian Trauma and Posttramatic
    Stress Disorder in a Representative National
    Sample of Women
  • By Resnick, H.S., et al.
  • The study assessed prevalence of crime and
    noncrime civilian traumatic events, lifetime
    posttraumatic stress disorder (PTSD), and PTSD in
    the last six months amongst a sample of 4,008
    U.S. adult women.
  • The study found that lifetime exposure to any
    type of traumatic event was 69, whereas exposure
    to crimes that included sexual or aggravated
    assault or homicide of a close relative or friend
    occurred among 36.
  • The overall prevalence of PTSD was 12.3
    lifetime and 4.6 within the past 6 months.
  • The rate of PTSD was significantly higher among
    crime versus noncrime victims (25.8 vs. 9.4).
  • History of incidents that included direct
    threat to life or receipt of injury was a risk
    factor for PTSD in women.

39
Description for Culture Women
  • Trauma Exposure and Posttraumatic Symptoms in
    Hawaii Gender, Ethnicity, and Social Context
  • By Klest, B., Freyd, J.J., Foynes, M.M.
  • This was a longitudinal cohort study of 833
    members of an ethnically diverse group in Hawaii,
    who were surveyed about their personal exposure
    to several types of traumatic events,
    socioeconomic resources and mental health
    symptoms.
  • Findings were that men and women are exposed to
    similar rates of trauma overall. However, women
    report more exposure to traumas high in betrayal
    and men report exposure to more traumas lower in
    betrayal.
  • Trauma exposure was predictive of mental health
    symptoms. Neglect, household dysfunction, and
    high betrayal traumas predicted symptoms of
    depression, anxiety, PTSD, dissociation, and
    sleep disturbance. Lower in betrayal traumas
    predicted PTSD and dissociation symptoms.
  • Results suggest that more inclusive definitions
    of trauma are important for gender equity.

40
Description for Culture Women
  • Although women are exposed to proportionately
    fewer traumatic events in their lifetime than
    men, they have a higher lifetime risk of PTSD
    (Seedat, Stein, and Carey, 2005)
  • Studies show risk factors for PTSD in women
    include
  • - higher incidents of sexual assault and
    intimate partner violence.
  • - peritraumatic dissociation (dissociation
    that occurs at the time of a trauma) is a strong
    predictor of PTSD
  • - pregnancy, traumatic childbirth, pregnancy
    loss
  • - neurobiological dysregulation resulting from
    sensitization to stress hormones
  • (epinephrine and cortisol)
  • - concurrent PTSD and increased alcohol use is
    seen significantly more in women

41
Description for Culture Women
  • Resilience and Recovery
  • Resilience reflects the ability to maintain
    stable equilibrium
  • Recovery connotes a trajectory in which normal
    functioning temporarily gives way to symptoms of
    depression, PTSD, or other
  • Creating a therapeutic alliance building trust
  • Client-centered
  • Validation
  • Non-threatening
  • Holistic - looking at various aspects of a
    womans life and environment
  • (Seedat, et.al., 2005 Olff, Draijer, Langeland,
    Gersons, 2007 Grieger, Fullerton, Ursano,
    2003)

42
References
  • Bell, C., Eth, S., Friedman, M., Norwood, A.,
    Pfefferbaum, B., Pynoos, R. S., ... Yager, J.
    (2007). Practice guideline for the treatment of
    patients with acute stress disorder and
    posttraumatic stress disorder. American
    Psychiatric Publ..
  • Bonanno, G. A. (2004). Loss, trauma, and human
    resilience Have we underestimated the human
    capacity to thrive after extremely aversive
    events?.American psychologist, 59(1), 20.
  • Chandra, A., Minkovitz, C.S. (2006). Stigma
    starts early gender differences in teen
    willingness to use mental health services.
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  • Geiger, T.A., Fullerton, C.s., Ursano, R.J.
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  • Ironson, G., Freund, B., Strauss, J. L.,
    Williams, J. (2002). Comparison of two treatments
    for traumatic stress A community-based study of
    EMDR and prolonged exposure. Journal of clinical
    psychology, 58(1), 113-128.
  • Kennedy, J. E., Jaffee, M. S., Leskin, G. A.,
    Stokes, J. W., Leal, F. O., Fitzpatrick, P. J.
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    posttraumatic stress disorder-like symptoms and
    mild traumatic brain injury. Journal of
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  • Klest, B., Freyd, J. J., Foynes, M. M. (2012).
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  • Kutz, I., Resnik, V., Dekel, R. (2008). The
    effect of single-session modified EMDR on acute
    stress syndromes. Journal of EMDR Practice and
    Research,2(3), 190-200.
  • Olff, M., Langeland, W., Draijer, N., Gersons,
    B.P. (2007). Gender differences in posttraumatic
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  • Penava, S. J., Otto, M. W., Pollack, M. H.,
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    anxiety, 26(12), 1086-1109.

43
References (continued)
  • Resnick, H. S., Kilpatrick, D. G., Dansky, B. S.,
    Saunders, B. E., Best, C. L. (1993). Prevalence
    of civilian trauma and posttraumatic stress
    disorder in a representative national sample of
    women. Journal of consulting and clinical
    psychology, 61(6), 984.
  • Ruglass, L. V. (2012). Helping Alliance,
    Retention, and Treatment Outcomes A Secondary
    Analysis From the NIDA Clinical Trials Network
    Women and Trauma Study. Substance Use Misuse,
    47(6), 695-707.
  • Russo, N. F. (1990). Overview Forging research
    priorities for women's mental health. American
    Psychologist, 45(3), 368.
  • Seedate, S.D., Stein, D.J., Carey, P.D. (2005).
    Post-Traumatic Stress Disorder in Women
    Epidemiological and Treatment Issues. CNS Drugs.
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  • Shapiro, F. (2004). Emdr The Breakthrough Eye
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    (2010). Dissociation of the personality in
    complex trauma-related disorders and EMDR
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