Concept Paper- Treatment of Post-Traumatic Stress Disorder Rodney A.

Ellis, PhD, LCSW, CMAT, CSAT

Post-traumatic stress disorder is a cognitive, psychological and physiological condition that occurs in response to a significant traumatic event. It is cognitive in that it affects the way we see the world. When we experience a traumatic event from which we had previously assumed (consciously or unconsciously) we were safe, our views of ourselves, the world, and the future are forced to change. We may, for example, being to see ourselves as less adequate to deal with the dangers of life, the world as a very dangerous place, and the future as bleak because of the danger of life and our own inadequacy. It is a psychological event because of the changes it can create in our emotional reactions as well as in our overall psychological functioning. Some who experience major traumatic events become hypervigilant (overly concerned that something will go wrong and constantly watching for it to do so). Some begin to reexperience the event in flashbacks and dreams. PTSD is physiological in that it affects the neural networks in the brain, blocking or depleting them in ways that prevent a careful, measured response to future stressful or traumatic events. The trauma that creates PTSD can be from a variety of sources. Children who are abused, abandoned, or neglected experience such trauma. Accident victims and survivors of natural disasters experience it, as do survivors of rape, domestic violence, and violent crime. Trauma and subsequent PTSD are frequent among soldiers and law enforcement personnel. There is even some evidence that an infant in the womb may experience trauma when its mother is confronted with a traumatic event. Although everyone experiences trauma at one time or another, not everyone develops strong reactions to it. Several factors influence the way in which we react to trauma. One is our own physical and psychological composition. Differing genetic compositions, childhood environments, and adult experiences tend to protect some people more than others from the effects of trauma. Another major factor is history of previous trauma. Those who are significantly effected by one trauma may tend to be more greatly effected by future traumas. Thus, multiple traumas can produce a cumulative effect, so that the sum total effect of the traumas is greater than the effect any one of them might have had alone. Individual reaction to trauma also depends on the circumstances of the one who experiences it. There is evidence that someone who reacts strongly to trauma on a given day might not react so strongly on another day. Theory suggests that this may be due to the frame of mind, psychological condition, and physical condition of the person at the time the trauma is experienced. Two diagnoses are used in the DSM-IV TR to identify types of trauma reactions. One is Acute Stress Disorder (ASD). ASD develops within one month of experiencing trauma, but least less than six months. it involves a cluster of symptoms such as anxiety, depression, dissociative episodes, and perhaps sleep disturbance. The second diagnosis is PTSD. PTSD can be diagnosed when the trauma reaction lasts more than

six months and has both the symptoms of ASD and several specific additional symptoms. Insufficiency of DSM-IV TR diagnostic criteria The Diagnostic and Statistical Manual of Mental Disorders (4th edition, hence the IV, text revision, hence the TR) contains the guidelines for providing a diagnosis for clients who suffer from psychological disorders. Being able to identify the name and nature of a psychological disorder (diagnose) is important for several reasons. First, it is a guide to treatment. We know what kinds of interventions work best for many of the diagnoses. Knowing what the problem is makes fixing it easier. For example, we know that certain disorders, such as bipolar disorder, are biochemical in nature and cannot be effectively treated with talk therapies alone. We also know that certain kinds of interventions have been shown to be particularly effective for other disorders. Cognitivebehavioral therapy has been found to be particularly effective for anxiety, for example. Another major advantage of the DSM-IV TR is that legitimizes therapists' work to state health boards and enables them to be compensated by insurance companies. State record reviews of mental health practitioners require a diagnosis for mental health treatment. Insurance companies also require a diagnosis in order to justify payment to the practitioner. Although the DSM-IV TR is critical to practice, it is important to keep its limitations in mind. At this point in their development psychiatry and psychology are far from perfect sciences. For the most part the disorders are collections of characteristics known as the diagnostic criteria that tend to group together in clusters in some people. If a cluster has been observed to group together with sufficient regularity and to cause similar difficulties in the lives of the people who experience it that cluster gets a name. Major Depressive Disorder, for example, is a condition characterized by a cluster of symptoms that include things like hopelessness, loss of pleasure and interested, and increased or decreased appetite. If enough of these symptoms exist for any individual with sufficient regularity that qualify (?) to receive that diagnosis. As time goes on and additional research is conducted more is learned about each disorder, so that the DSM-IV TR becomes more and more accurate. Still each of the 4 revisions (II, III, IV, and IV TR) has incorporated substantial changes. The DSMIV, slated for use in the fall of 2013, has several more. Many of the diagnoses, then, are useful, but lack the accuracy of medical diagnoses. For example, it is possible to test the saliva of a patient, identify the flu virus, and say with certainty that a patient has the flu. In psychology one may administer the Beck Depression Inventory and say with 90+ certainty that (if a client has responded honestly) the client is or is not depressed. The issues arise in the lack of absolute certainty (10ish percent probability of error) and in the fact that although depression may be present it may be a symptom rather than a diagnosis. Other conditions, for example, PTSD and bipolar disorder can also cause depression.

The limitations of the DSM-IV TR are important for understanding ASD, PTSD, other stress-related conditions, and their treatment. At least two of those limitations make accurate diagnosis and treatment of trauma-related conditions more difficult. The first is the requirement that for either diagnosis the trauma survivor must experience an event that threatens their own life or physical well-being or the life or physical well-being of another. In my own clinical experience I have observed people whose trauma reaction was as great as that of someone suffering from ASD or PTSD, but who had experienced trauma that was damaging or threatening to their emotional well-being or world view rather than their physical well-being. The DSM-IV TR does not recognize these people and, leaves them without a diagnosis that authorizes, directs, for compensates for treatment. The second limitation of the DSM-IV TR with regard to trauma reactions is that it does not provide for people who experience multiple symptoms of ASD or PTSD but do not experience enough symptoms to qualify for a diagnosis of either. This can lead some clinicians to misdiagnose what is really a stress reaction as something else such depression, a personality disorder, or bipolar disorder. These kinds of misdiagnoses have severe negative implications. In the case of depression the clinician would likely treat a symptom rather than the problem. Although the depression might improve the overall effects of the trauma would remain. If the inaccurate diagnosis was a personality disorder the clinician would regard the condition as difficult, perhaps impossible to improve, and might focus on behavioral interventions designed to regulate behavior rather than cure a broken mind. If the clinician concluded that the trauma reaction was bipolar disorder she might refer the patient for psychotropic medications. If the medical practitioner agreed the patient might be given mood stabilizers which at best would have no effect and at worst could worsen the problem. PTSD and trauma reactions as pretenders The above discussion of the inadequacy of the DSM-IV TR highlights one of the challenges PTSD and other trauma reactions create for the therapist. Not only are they important clinical conditions in their own right, they are also pretenders that masquerade as other disorders, at least in the minds of clinicians. This has several implications for treatment. The first is that the initial psychosocial evaluation of any client presenting with multiple symptoms that include symptoms of trauma reactions should include a ver thorough trauma history. The history should not include only life- or physicallythreatening events and should not include only solitary events. Rather, it should include events that were substantially traumatizing to the client as well as a history of multiple traumatic events. This is particularly true when those multiple events have a common theme. Rejection and abandonment are examples of such themes. Assessment should also include an interpretation of the client's symptoms in the light of the effects of trauma. If trauma is present in the history and multiple symptoms of traumatic reactions are present that do not rise to the level of ASD or PTSD the clinician should consider incorporating trauma treatment into the overall treatment plan.

This is not to say that the sole focus should be trauma, but many of the modern treatments for trauma also have positive outcomes for many other disorders. When the symptoms are severe simultaneous treatment of other disorders must also be a priority. For instance, extreme moods swings resulting in deep depression and self-destructive manic episodes should receive attention as possible bipolar disorder. It is critical to remember that many disorders may coexist with others. It is entirely possible for a client to have both bipolar disorder and PTSD or some other stress reaction. As a matter of fact, it's pretty hard to imagine that someone with Bipolar Disorder would not have some pretty significant stress reactions. The symptoms of the stress reactions would likely compound the effects of Bipolar Disorder by making the client more reactive to current stressful situations and events. PTSD and trauma reactions in neurophysiology PTSD and other trauma reactions are known to have physical effects on the brain. Although recent discoveries about brain functioning show the following explanation to be overly simple, it is nonetheless generally true. Trauma reactions place severe limitations on the interaction between the parasympathetic nervous system, the sympathetic nervous system, and other parts of the brain. In simple terms this is often described as limitations on the interaction between the left and right sides of the brain. The right side of the brain has primary responsibility for several functions. One of these is the fight, flight, or freeze response. When we are faced with danger that part tell us to react with one of those responses: fight, flee, or freeze. Although these are very functional in the short-term for survival, they are not very functional for handling many trauma-inducing situations. The left side of the brain is intended to help with those situations, soothing the right and providing alternative responses that are more functional in everyday situations. For people who have PTSD and other strong trauma reactions the communication between the sides of the brain (or more accurately between the sympathetic nervous system, the parasympathetic nervous system, and the rest of the brain). Brain scans indicated the probability that neural networks are either damaged or silence, preventing the two sides of the brain from communicating. The good news is that both the neural networks and the communication within the brain can be restored. Several modern forms of treatment have been found to be particularly effective in treating trauma reactions, specifically PTSD. Neural imaging has shown the return of normal functioning to previously under-functioning of the brain, suggesting the restoration of neural networks. Although I am unaware of any studies done to examine this, it is likely that some of the older forms of therapy that have been effective for trauma also restored neural networks. These forms of therapy include behavioral methods such as systematic desensitization and flooding. Trauma, PTSD, cognitions, and ideologies

In addition to the changes produced in the brain, trauma also produces changes in the way survivors think (cognitions). These changes include that way in which the client views self, the world, and the future. Ideas about self often include things like, "I'm inadequate to deal with the things life will bring me." or "I am not worthy of love.". The first often occurs in response to observed death, physical injury, divorce, or job loss. The second is common among abused children, foster children, and adults who have made frequent poor choices in romantic relationships. These are only examples. there are many permutations of these and many other ways of affected thinking. Groups of related ways of thinking can be thought of as ideologies. One such ideology was mentioned earlier, "I am inadequate to deal with the world." "The world is a dangerous place." My future is bleak and terrible things are likely to happen to me." This ideology often leads to the depression, anxiety, and hyper-vigilance common in trauma reactions. Another ideology suing the examples above, would be, "I am not worthy of love." "No one in the world will ever love me." "The only way I can ever have love in the future is by sacrificing me or some part of me (sex, servitude, dependency) in order to get it." Just as the brain must be healed to successfully treat trauma reactions, these thought processes must also be healed. They must first be identified and articulated in the client's own words. Once the ideologies and their component cognitions have been identified cognitive behavioral methods can be used to change them. Trauma and somatization Somatization refers to the usually unconscious process of expressing the effects of trauma, stress, and other psychological conditions in bodily sensations. Some of these are commonly recognized and acknowledged. An example would be those who have digestive issues such as "nervous stomach" or colitis that are related to or affected by anxiety. Other would be the relationship between heart attack and stroke. Perhaps less commonly recognized is the manner in which conditions such as fibromyalgia and lupus can be impacted by psychological issues. Somatization presents both challenges and opportunities. Perhaps the greatest challenge include is differentiating between conditions that are purely physical, conditions that are psychologically induced, and conditions in which physical illness is compounded by psychological issues. Among the opportunities are the potential for the physical manifestation to be used in monitoring and treating a stress reaction. Somatic reactions are frequently used in modern forms of treatment by asking a clients if there is a place where they physically experience discomfort that arises in therapy. Often they are able to say, "Yes, I feel it in my chest." or "I feel it in my stomach." although these may not be medically-relevant sensations, they are very meaningful in psychology. Some modern methods use monitoring of those sensations to track increases or decreases in emotional distress levels. Others actually use the

somatization as a part of the treatment by focusing attention to the affected areas or encouraging the expression of emotion that is "held" in that area. Healing the mind, the brain, the body, and the heart Stress reactions, then, including ASD, PTSD, and other non-diagnosable reactions, are cognitive, psychological, and physiological conditions that, as complex conditions, are best approached through complex treatment. Several modern methods address the multiple components. Methods like Eye Movement Desensitization and Reprocessing (EMDR), Mindfulness Meditation, Rapid Resolution Therapy, and Somatic Experiencing. (Kathy, does Pia's approach have a name? If so it could go here.) Other healing methods include the use of metaphor, imagery, parable, storytelling, and unconditional positive regard (therapisty word for good old fashioned true love). An effective treatment protocol would include the following: 1) Careful assessment that includes a thorough trauma history, differential diagnosis (recognizing the presence of other disorders), and identification of any addictions that might be present (I forgot to talk about this earlier. Lots of people with trauma reactions also have addictions.) 2) Development of an adequate rapport to be able to venture into very intimate psychological areas. Pat Carnes call therapists "privileged voyeurs". 3) Selection of an evidence-based modality such as the ones identified above with which the client is comfortable and with which positive results are obtained. 4) Careful monitoring of the client's progress to determine whether the treatment is being successful. 5) Frequent injection of metaphor, imagery, parable, story telling into sessions that are consistently conducted with unconditional positive regard. Trauma, the loss of moral authority, and healing This is what I thought this concept paper would be about. As it turns out, this is only a part of the overall paper. I believe that the loss of trust in and regard for moral authority is one component of an overall trauma reaction such as PTSD. In it the brain is injured in such a manner that the capacity for moral judgement, along with other capacities, are lost. In addition, previously held ideologies trusting in and submitting to moral authorities such as God, the law, or the legal system, are rejected. they are replaced by other thought clusters (ideologies) that reject the existence of moral authority, reject the legitimacy of moral authority, or reject the morality of the moral authority itself. Treatment would consist of an intervention to heal the damage done to the brain as well

as work to replace the problem ideologies with ideologies that are more realistic and functional.