Psychopathology of Post-Traumatic Stress Disorder

• Specify the diagnostic criteria of the clinical disorder you have selected.
• Identify two conditions that share similar signs and symptoms to this disorder.  Discuss the process of differential diagnosis and how would you distinguish between these disorders and the disorder that you have selected during an assessment.
• Identify the prevalence rates for the clinical disorder you have selected, including prevalence rates for at least two of the following groups:  gender, race, ethnicity, social economic status, differently abled or sexual orientation.
• Discuss some of the ways in which this disorder could impact an individual’s social functioning (home, school, work, family, and relationships).
• Discuss two theories that have been used to explain the etiology of the disorder. What are the implications of these theories for the treatment of the disorder?
• Identify at least two psychosocial and psychopharmacological interventions used to treat this disorder. Discuss why these interventions are shown to be effective. Discuss the side –effects of the psychopharmacological interventions.
• Identify two community-based resources located in the state you reside that an individual with this disorder might find useful. Discuss why these resources could be important for persons who have this disorder and how to access them.

Post-Traumatic Stress Disorder: Diagnostic Criteria

Post-Traumatic Stress Disorder (PTSD) is a genuine condition which one can create in the wake of having experienced or seeing awful accidents or circumstances. As indicated by the National Institute of Mental Health (NIMH), PTSD develops in people who have encountered a risky, stunning, and frightening occasion. While it is normal to feel fear amid an awful accident, that solitary occasion can debilitate a person for the rest of his or her life. PTSD standout amongst the most widely recognized disorders that at present influences most Americans.

In 2013, the American Psychiatric Association overhauled the PTSD demonstrative criteria in the fifth release of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). PTSD is incorporated into another class in DSM-5, Trauma-and Stressor-Related Disorders. Most of the conditions incorporated into this characterization expect presentation to a horrendous or distressing occasion as an indicative measure.

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PTSD has 8 analytic criteria required for it to be diagnosed.  All symptoms must be related to the traumatic event which applies to grown-ups, adolescents, and kids 6 years and older. The analytic measures of PTSD are as followed; Criterion A: stressor (one required), Criterion B: intrusion symptoms (one required), Criterion C: avoidance (one required), Criterion D: negative alterations in cognitions and mood (two required), Criterion E: alterations in arousal and reactivity, Criterion F: duration of disturbance, Criterion G: functional significance, Criterion H: exclusion (American Psychiatric Association, 2013).

Criterion A focusses on if an individual was exposed to death, compromised passing, real or undermined substantial damage, or real or compromised sexual savagery, in the following way(s):

 1. Direct presentation to a horrible event(s)

2. Witnessing the injury

3. Learning that the horrendous accident was presented to a relative or companion.

4. Experience repeated or extreme exposure to aversive subtleties of horrible event(s). (e.g. work obligations)

Criterion B specifies that the horrendous accident is constantly re-experienced in the following way(s): attracts regard for interruption indications from a horrendous accident that is relentlessly re-experienced in the accompanying ways:

1. Recurrent automatic, undesirable, and meddlesome recollections.

2. Recurrent troubling bad dreams identified with the awful accident(s).

3. Flashbacks

4. Emotional misery when presented to inner and outer signs that are like the horrible accident(s).

5. Physical reactivity after presentation to awful updates

Criterion C looks at if the avoidance of stimuli connected with the horrendous event boosts after the trauma, in the following way(s): 

1. Efforts to abstain from troubling recollections, sentiments, musings, or emotions identified with the horrible accident(s).

2. Efforts to maintain a strategic distance from outer notices of that excite considerations, recollections, and emotions connected to the horrible accident(s).

Criterion D focus in on negative musings and sentiments that started or compounded after awful mishap (s), as confirm by the following:

1. Inability to recall key highlights of the awful accident (s).

2. Never consummation and performed negative convictions about oneself, others, or the world.

3. Blaming one’s self or others for awful mishap (s)

4. Continuous negative passionate state.

5. Decreased enthusiasm for exercises

6. Feelings Isolated.

7. Difficulty encountering positive feelings.

Criterion E focuses on the marked changes in excitement and reactivity that started or intensified after the injury, in the following ways:

 1. Irritability or animosity towards individuals and items.

2. Risky and pointless conduct.

3. Hypervigilance

4. Exaggerated startle reaction.

5. Difficulty with concentrating

6. Difficulty resting.

Criterion F specifies that the symptoms are going on for over a month.

Criterion G references symptoms to create distress or functional impairment (e.g., social, occupational).

Criterion H distinguishes the symptoms are not attributed to the side effects of medicine, substance use, or other medical conditions.

Shirking of injury-related boosts after the injury, in the accompanying way(s):

Negative musings or emotions that started or declined after the injury, in the accompanying way(s):

Injury-related excitement and reactivity that began or intensified after the injury, in the accompanying way(s):

Differential Diagnosis of PTSD

Two conditions that share similar signs and symptoms to PTSD are General Anxiety Disorder (GAD) and Major Depressive Disorders (MDD). Clinicians and researchers have found that PTSD, MDD and GAD share similar symptoms however, each disorder have some distinctive highlights. Individuals with depression move gradually, and their responses can appear to be straightened or dulled. Individuals with anxiety will in general be progressively keyed up, as they battle to deal with their propelling thoughts.

Side effects of Major Depression

• depressed mood
• absence of enthusiasm for enjoyable exercises
• absence of vitality
• increment or decline in appetite
• insomnia or hypersomnia
• sentiments of blame or worthlessness
• slowing of movement
• trouble concentrating
• suicidal thoughts or behaviors.

For a diagnosis of major depressive disorder, an individual need experienced at least five of these symptoms for at least two weeks. Individuals encountering a portion of these manifestations may likewise be determined to have depressive disorder (dysthymia), premenstrual dysphoric disorder, or a depressive disorder due to another condition. They may likewise meet the criteria for bipolar disorder if they additionally encounter symptoms of mania.

Side effects of Generalized Anxiety Disorder

• over the top stress
• restlessness 
• being effortlessly exhausted
• trouble concentrating
• irritability
• insomnia or hypersomnia
• muscle pressure.

For a diagnosis of generalized anxiety disorder, an individual need to encounter these symptoms most days for more than six months, and they cause trouble in your day by day life. Different sorts of anxiety disorders include panic disorder, separation anxiety or phobias.

 Byllesby, Charak, Durham, Wang, & Elhai (2016) suggested that clinicians and researchers have found differential diagnosis can be difficult because of the similarities in symptoms and diagnostic specificity that most disorders share. Due to the difficulty of differential diagnosis Byllesby et al (2016) studied the negative effect in the association between post-traumatic stress disorder, (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD).  Depressive disorders are not just about being moody or sad, it is a serious illness that can last months or even years and it can be caused by the same traumatic events that cause PTSD. Most of the symptoms listed in the DSM-5 for PTSD and MDD overlap, these symptoms are as followed: auditory & visual hallucinations, anxiety, feelings of guilt, loss of interest in previously pleasurable activities, decreased energy, fatigue, difficulty concentrating, memory problems, difficulty making decision, suicidal or homicidal ideations, and irritability. (APA, 2013). PTSD and MDD, Anxiety disorders (AD) are also caused by traumatic events and stress. (Pomeroy, 2015). The fact is that people react to trauma and difficult situations differently based on their race, gender, life experiences, coping skills, values, culture, beliefs, etc. (Pomeroy, 2015). There is no set answer as to why a person may develop a long-lasting mental health condition to an event, another may develop PTSD, and yet another may develop an anxiety or depressive disorder. Some of the overlapping symptomology for PTSD and anxiety disorder include restlessness, difficulty concentrating, irritability, excessive worrying, difficulty sleeping, sudden and repeated attacks of intense fear, feelings of panic, fear or avoidance where panic where panic has occurred. (APA, 2013).

Determining the correct diagnosis is always important and as professionals it’s important to remember the diagnostic process because if we don’t we run the risk of making mistakes that take us down the path of misdiagnosis. Differential diagnosis is arguably one of the most critical processes that can bring about consequences to a patient’s outcome and safety.  The process of differential diagnosis is broken down into 6 step or rules: “1) ruling out Malingering and Factitious Disorder, 2) ruling out a substance etiology, 3) ruling out an etiological medical condition, 4) determining the specific primary disorder(s), 5) differentiating Adjustment Disorder from the residual Other Specified and Unspecified conditions, and 6) establishing the boundary with no mental disorder.” (First & American Psychiatric Association, 2014).

According to Pomeroy (2015) when a client who displays both anxiety or depressive symptoms that overlap with some PTSD diagnostic criteria, only the client who has experienced a traumatic event and meets the full criteria can be diagnosed with PTSD. According to the American Psychiatric Association (APA, 2013) what separates MDD from PTSD is that depressive disorder does not include any “PTSD Criterion B or C symptoms, nor does it include a number of symptoms from PTSD Criterion D or E.” (pg. 279). MDD isn’t only diagnosed when there is a traumatic experience, unlike PTSD. When distinguishing anxiety disorder from PTSD, one must consider these factors: not all intrusive thoughts are related to an experience traumatic event, compulsions are often present, and other symptoms of PTSD or acute stress disorder are generally absent. Most symptoms of anxiety and depressive disorder that overlap with PTSD aren’t related to a traumatic event.

Prevalence Rate PTSD

The lifetime prevalence rate of PTSD among adult Americans is 6.8%. (Kessler, Berglund, Delmer, Merikangas, & Walters, 2005). According to Kessler et al (2005) and APA (2013), the “twelve-month prevalence among US adults is about 3.5%.”  According to the APA (2013), PSTD is more prevalent among females than among males across the lifespan. (pg. 278).  Bowler et al (2017) who investigated PTSD, gender and risk factors for 9/11 survivors suggested that it is very typical for females to experience PTSD for a longer period of time than males.  Bowler et al (2017) have suggested that gender is a risk factor for PTSD.

“Gender differences may, in part, reflect exposure to different trauma types or, different exposure rates, or alternatively, differential effects of the perceived impact of the event.” (Frans, Rimmö, Åberg, & Fredrikson, 2005).  According to the DSM-5, some of the increased risks for PTSD in females appears to be attributable to a greater likelihood of exposure to traumatic events, such as rape, and other forms of interpersonal violence.” (APA, 2013).  The lifetime predominance rate of PTSD among men was 3.6% and among women was 9.7%. The year predominance was 1.8% among men and 5.2% among women. (Kessler et al, 2005).  PTSD is said to be at a lower rate among older adults when compared to the general population. Veterans are at a higher risk for PTSD and they are more likely to develop it. About 2.5 million American service members who have served in Iraq and Afghanistan since 2001 has been affected by PTSD and it has become a significant problem. (Mustillo, Kysar-Moon, 2017).

Many studies that have been conducted were unable to find the lifetime prevalence rate for the general US population racial and ethnic differences. (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). According to Robert et al (2011) “two national studies of the prevalence of PTSD report conflicting results regarding racial differences.” “Breslau et al. (2006a) found no statistically significant difference in PTSD between Blacks or Hispanics and Whites, but Himle et al. (2009) found Blacks had a higher lifetime prevalence of PTSD than Whites.” (Robert et al).  Robert et al suggested concluded that the studies on racial and ethnic different limited by their data collection from a specific geographic area or by their focus on a limited number of event types.

The impact of PTSD on an individual’s social functioning

PTSD is not a respecter of gender, race, age, etc. This disorder can begin after the very first year of life and it can significantly impact an individual’s social functioning.  According to Pomeroy (2015) that when individuals are impacted by trauma and stressor-related disorders the individual and their social support system are significantly affected. Volt et al (2017) suggested that social support systems are very important for women compared to men because they act as a protective factor against PTSD symptoms. PTSD can hinder a person’s ability to work and maintain relationships. Many of the symptoms of PTSD can cause an individual to miss work and become an ineffective worker. An individual may have problems concentrating at work and may have problems sleeping, which makes it hard to pay attention at work, be punctual, stay organized, and make decisions. Satel (2011) the author of PTSD’s Diagnostic Trap mentioned that the cruelties of war will leave many men and women irretrievably damaged to the point where they will not be able to participate in a competitive workplace.

According to APA (2013) “in community and veterans samples, PTSD is associated with poor social and family relationships, absenteeism from work, lower income, and lower educational and occupational success.”  (pg. 279). Volt (2017) also suggested that although PTSD has negative implications for family functioning and satisfaction, it doesn’t undermine the ability of veterans to participate in main roles (e.g. employee, parent, etc.).  The National Center for PTSD mentioned that PTSD can make it hard for family members to get along with each other and make an individual suffering from the disorder withdraw or distance themselves from family. The duration of PTSD can take a toll on family members, they sometimes start to lose hope that their loved ones will never get back to normal. Families often react to PTSD with fear & worry, sympathy, other mental disorders (e.g. depression), avoidance, guilt and shame, anger, negative feelings, drug and alcohol abuse, sleep problems, and health problems.

Theories of PTSD Etiology

Two theories that have been used to explain the etiology of PTSD are Mower’s two-factor learning theory known as the behavioural theory and information-processing theory. (Litz & Roemer, 1996). Mower’s two-factor learning theory suggests that prospectively traumatizing event serves as an unconditioned stimulus that evokes great fear and anxiety. Other stimuli that are also present at the time of the event become conditioned stimuli for fear and anxiety through classical conditioning. Litz et al (1996) stated that the fact that trauma is so intense, stimulus generalization and higher order conditioning processes, over time, lead to a wide range of stimuli being able to evoke conditioned emotional responses.  In other words, the behavioural model theory suggests that when an individual avoids trauma-related cues, the individual unconsciously cripple the recovery process that requires the elimination of conditioned emotional response.  The behavioural theory suggests that “successful treatment involves repeated, prolonged exposure to the range of conditioned stimuli so that extinction can take place.” (Litz et al, 1996).

The Litz et al (1996) mentioned that theorists have diversified the behavioural theory of PTSD to integrate constructs information-processing theory. The information-processing theory proposes that emotional experiences that are coded in memory in immensely organized, semantic networks that incorporate stimulus-response and meaning elements. The authors also suggested that trauma networks in individuals with PTSD are likely to change an individual’s processing of information and make them become hyperaware of threatening material, interpret vague cues as threatening.  “Information-processing theorist has proposed that for emotional change to occur, PTSD patients need to fully access their network of trauma memories so that they can accommodate corrective information as a form of treatment.” Th theorists hope that when individuals with PTSD are exposed to emotions associated to trauma and think about what the event and their emotional reactions mean to them they will be able to form new corrective associations to those emotions.

Psychosocial and psychopharmacological interventions of PTSD

When trauma reactions are severe and go on for some time without treatment, they can cause major problems in an individual’s life. Pharmacotherapy and Psychotherapy are interventions used to address the symptoms of PTSD since it’s a disorder that is treatable.  The symptoms of PTSD can possibly go away but that doesn’t mean that it is curable. According to Sadock, Ruiz (2015) the two-pharmacotherapy intervention used for PTSD are (2015) imipramine (Tofranil) and amitriptyline (Elavil). Both medications are tricyclic drugs that have proven its effectiveness in several controlled clinical trials. According to Puetz, Youngstedt, & Herring (2015) “reductions in PTSD symptom severity in response to pharmacotherapy among combat veterans were greater for SSRI and Tricyclic antidepressants (Δ = 0.63) compared with other medications (Δ = 0.10) regardless of treatment duration.” Imipramine and amitriptyline are effective interventions for PTSD because they have been able to reduce the symptoms of PTSD in veterans. (Puetz, 2015).  According to the Mayo Clinic (2017), imipramine and amitriptyline has several side effects, such as: abdominal or stomach pain, agitation, blurred vision, burning, crawling, itching, numbness, prickling, “pins and needles”, or tingling feelings, chest pain or discomfort, cold sweats, confusion about identity, place, and time continuing ringing or buzzing or other unexplained noise in the ears.

The two most effective psychosocial interventions used to treat PTSD is exposure therapy and group therapy. (Sadock et al 2015). Exposure therapy allows individuals with PTSD re-experience a trauma event through imaging techniques or in vivo exposure. Exposure therapy can be acute, but its primary goal is to review the intense event in an effort to develop more appropriate responses to similar situations in the future. The second approach of exposure therapy is to teach a patient’s methods of stress management for PTSD.  Sadock et al 2015 mention that group, individual, and family therapy has been shown to be one of the most effective forms of treatment for PTSD. Group therapy gives an individual the opportunity of sharing traumatic experiences in a group setting with others who are also seeking support for PTSD. Group therapy has been shown to be effective with Vietnam veterans as well as other survivors of catastrophic disasters. (Sadock et al 2015).

PTSD Resources in New Jersey

The first community-based resources located in the state of New Jersey that is geared towards PTSD that an individual might find useful is All Access Mental Health (AAMH). AAMH is a private non-profit community based behavioral healthcare agency that was founded to respond to the mental health needs of the community. The programs and services that they offer are as followed: behavioral health home, outpatient services, partial care services, and case management services & supportive housing.  Their behavioral health home integrates behavioral health and primary care utilizing a holistic approach to wellness such; individual & family psychotherapy & counseling, on-site pharmacy, wellness room-fitness equipment, and health & wellness groups, including yoga, smoking cessation, medication education groups. AAMH child and adult outpatient services provide clients with personalized and confidential counseling which includes: psychosocial evaluation and assessment, psychiatric evaluation, psychopharmacological management, emergency psychotherapy and counseling and psychiatric services. Case management services and supportive housing provides clients with the support needed to help sustain themselves in the community. An individual dealing with PTSD might find AAMH because they are able to meet their needs on a physical and a mental level.

The second community-based resources located in the state of New Jersey that is geared towards PTSD that an individual might find useful is Hampton Behavioral Health Center (HBHC).  HBHC offers both outpatient and inpatient treatment for adults, dually diagnosed adults, older adults, and adolescents.  The programs that they offer are tailored to an individual need. HBHC programs and services are as followed: comprehensive evaluation & assessment, individual and group therapy, family education therapy, individualized biopsychosocial treatment plan, aftercare and discharge planning. HBHC also offers a specialized military programming for service members and their families. They offer an intensive program for veterans who have been diagnosed with service-related trauma. The program focuses on enhancing the coping skills and maximizing resiliency in veterans. Veterans can participate in a wide array of group topics for military programs that are as followed: anger management, anxiety management, coping skills, depression management, grief and loss, healthy relationships, mindfulness, and reintegration into civilian life.

The programs listed above are very family and individually centered to address the needs of PTSD. We know that PTSD isn’t just something that an individual experience by themselves, it can affect an individual’s personal life, work life, and other aspects of their daily life. Both programs offer support groups and have many client testimonials that would benefit an individual suffering from PTSD. To access both programs an individual dealing with PTSD wouldn’t need a referral they would simply walk in and speak to someone. Another great thing about both programs is that they can provide services to individuals based on their income, family size and insurance coverage-sliding scale fee. Both programs also accept Medicare and Medicaid.

Reference

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