Trauma- and Stressor-Related Disorders

1
Trauma- and Stressor-Related Disorders

• University of Manoa
• Anna Weihl, Christine Keanu, Genevieve Parks,
  Patricia Kaleiwahea

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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

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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

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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

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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
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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.

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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

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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

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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

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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

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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

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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

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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

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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.

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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.

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• 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.

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• 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.

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Acute Stress Disorder/YouTube Video

• http//www.youtube.com/watch?vAl1A0t1vWzk
• (1 minute, 55 seconds)

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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/

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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

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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.

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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).

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Posttraumatic Stress Disorder YouTube Video

• http//www.bing.com/videos/search?qGeorgeCarlin
  PtsdFormVQFRVPviewdetailmid9B6B008519D3B7220
  36E9B6B008519D3B722036E

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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.

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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.

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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.

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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.

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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

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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

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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.

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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

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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

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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.

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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.

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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
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