Task 6. Imagery, imagery treatments and PTSD
Problem statement
What is PTSD and how can you treat it?
Learning goals
PART 1. PTSD
What is PTSD (characteristics, specifiers, comorbidity, prevalence, etiology etc)
- Criteria A is the official criteria for a trauma
If it’s about physical violence, someone has to feel like (s)he is dying/injured.
Bovin, M. J., Wells, S. Y., Rasmusson, A. M., Hayes, J. P. and Resick, P. A. (2014) Posttraumatic
Stress Disorder. In: The Wiley Handbook of Anxiety Disorders
Description of disorder
Currently, under the DSM-V, PTSD is classified within the new category of ‘Trauma- and
stressor-related disorders’ and has the following criteria:
A. Exposure to actual or threatened death, serious injury, or sexual violence 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 traumatic event(s) occurred to a close family member or close
friend. In cases of actual or threatened death of a family member or friend, the
event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g., first responders collecting human remains; police officers repeatedly
exposed to details of child abuse).
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring. (Such reactions may occur on a continuum, with
the most extreme expression being a complete loss of awareness of present
surroundings)
4. Intense or prolonged psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after
the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
, 2. Avoidance of or efforts to avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories, thoughts, or feelings
about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or
the world
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions
E. Marked alterations in arousal and reactivity associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically
expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration
6. Sleep disturbance
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance or another
medical condition.
Specify whether:
With dissociative symptoms: The individual's symptoms meet the criteria for post
traumatic stress disorder, and in addition, in response to the stressor, the individual
experiences persistent or recurrent symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as
if one were an outside observer of, one's mental processes or body (e.g., feeling as if it
was a dream; feeling a sense of unreality of self or body or of time moving slowly)
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (the
world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months
after the event (although the onset and expression of some symptoms may be immediate).
,Epidemiology of PTSD
Although many people experience potentially traumatic events (PTE) over the course of
their lifetimes, PTSD can only be diagnosed following a traumatic event; the event cannot
just be a stressful life experience.
Exposure to potentially traumatic events
The majority of adults will experience at least one PTE during their lifetime, with the majority
experiencing more than one. Studies suggested that 61% of men and 51% of women had
experienced a traumatic event during their lifetime. Additionally, among those who had
experienced a traumatic event, multiple incidences of traumatic exposure were more
common than not. So, most individuals will experience at least one traumatic event during
their lifetime.
A number of studies have found that men are exposed to more traumatic events during their
lifetime than women. Men and women experience different types of traumatic events. Men
tend to experience more warzone and combat traumas, physical assaults, and accidents,
whereas women experience higher rates of child sexual abuse, molestation, rape, and
intimate partner violence.
Overall prevalence op PTSD
Immediately following a trauma, most people experience an increase in psychological
distress. For the majority of these individuals, these symptoms will quickly remit. However, a
substantial minority of people that have experienced a traumatic event will later be
diagnosed with PTSD. The NCS data suggested that the lifetime prevalence estimate of PTSD
is approximately 8% among the general population. In addition, this study found that
women’s lifetime prevalence estimates of PTSD (10%) were twice as high as men’s (5%). It is
suggested that off those exposed to a traumatic event, 23.6% of people met criteria for PTSD
over the course of their lifetimes. In other Western countries, the estimates found for PTSD
were lower.
Conclusion
Research suggests that although a large percentage of individuals will be exposed to
traumatic events during their lifetimes, the majority of these people will recover naturally.
However, a substantial minority of individuals will be diagnosed with PTSD after trauma
exposure.
Natural history
The majority of studies found that rates of PTSD decreased after a traumatic event.
However, the course of PTSD does not appear to be as clear as these studies would suggest.
A sizable minority of studies suggest that rates of PTSD increase, rather than decrease, after
a traumatic event. Different studies found different periods of evolution for PTSD symptoms.
Four possible symptom trajectories are proposed:
1. Resilience the ability to maintain equilibrium after a trauma. These individuals were
proposed to demonstrate few, if any, symptoms following a traumatic event, and
maintain their low symptom levels over time.
2. Recovery these individuals experience moderate disruptions in normal functioning
after a traumatic event, which decreased steadily over the course of time.
, 3. Chronic individuals who experienced severe disruptions in functioning immediately
after the traumatic event and maintained these high symptom levels over time.
4. Delayed individuals who initially demonstrated moderate disruptions in functioning,
and whose symptoms steadily increased to severe levels over time.
Other studies have also found evidence of differing trajectories, ranging from two to five
unique trajectories (somewhat varying from each other), with the majority of individuals
being classified as resilient. There is some debate about the validity of the delayed onset
trajectory, which was identified in a number of studies. PTSD could not be detected at first
because of other confounding variables. Furthermore, individuals with PTSD could have
recovered from their initial symptoms and had then been reactivated by another traumatic
event. It is also possible that people develop coping strategies that reduce symptoms in the
short term, when these methods stop working, the symptoms re-emerge. There is also a lack
of clarity about the definition of this trajectory.
The research reviewed thus far has suggested that, after exposure to a traumatic event,
most individuals will experience some PTSD symptoms which will remit over weeks or
months (resilient). However, for individuals who do not remit and are diagnosed with PTSD,
the course is often chronic. A number of studies have found that, if left untreated, PTSD can
persist for many years. For those who do recover, the rates of, and times to, remission vary
by study.
Impairment
Occupational and academic functioning
Individuals with PTSD are significantly more impaired in occupational and academic
functioning. These impairments manifest in terms of both objective measures and job
satisfaction. It is, for example, suggested that individuals with PTSD had 150% enhanced
odds of unemployment at the time of the interview. Even if individuals with PTSD are
employed, their diagnosis can affect their occupational functioning, including increased
productivity loss and work cutback days. These impairments increased as a product of PTSD
symptom severity. In addition, individuals with PTSD are at 40% enhanced odds of high
school and college failure. These difficulties in school are, also, directly associated with PTSD
severity.
Marital and family functioning
People diagnosed with PTSD consistently report greater marital dissatisfaction and higher
rates of marital separation and divorce. PTSD symptoms may affect these relationships in
that difficulties with effective trauma disclosure combined with poor conflict resolution skills
may lead to poor communication between individuals with PTSD and their family members.
This lack of communication may serve to cause or exacerbate relationship problems for
individuals with PTSD.
Parenting
A strong association has been found between PTSD and parenting difficulties. Parental PTSD
was associated with both increased offspring internalizing problems and parental physical
aggression toward children. PTSD symptoms were associated with impaired attachment to
children, child behavior problems, and decreased parenting satisfaction. These findings
suggest that parental PTSD affects not just the behavior of the parent, but also the behavior
of the children.
