Discussion: The Instant Effects of Acute Stress Disorder & PTSD Mechanisms

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+ Chapter 4 Mental Consequences ◼ Crisis – A specific set of temporary circumstances that results in a state of upset and disequilibrium, characterized by an individual’s inability to cope with a particular situation using customary methods of problem solving – The Impact Stage – The Recoil Stage – The Reorganization Stage ◼ Acute Stress Disorder – is acute stress that is experienced in the immediate aftermath of a traumatic event ◼ Posttraumatic Stress Disorder – the development of characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience +Causes, incidence, and risk factors PTSD can occur at any age. It can follow a natural disaster such as a flood or fire, or events such as: ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ Assault Domestic abuse Prison stay Rape Terrorism War For example, the terrorist attacks of September 11, 2001 may have caused PTSD in some people who were involved, in people who saw the disaster, and in people who lost relatives and friends. Veterans returning home from a war may develop PTSD. The cause of PTSD is unknown.

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Psychological, genetic, physical, and social factors are involved. PTSD changes the body’s response to stress. It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters). It is not known why traumatic events cause PTSD in some people but not others. Having a history of trauma may increase your risk for getting PTSD after a recent traumatic event. + Symptoms Symptoms of PTSD fall into three main categories: 1. “Reliving” the event, which disturbs day-to-day activity ◼ Flashback episodes, where the event seems to be happening again and again ◼ Repeated upsetting memories of the event ◼ Repeated nightmares of the event ◼ Strong, uncomfortable reactions + Sx cont. 2. Avoidance ◼ Emotional “numbing,” or feeling as though you don’t care about anything ◼ Feeling detached ◼ Being unable to remember important aspects of the trauma ◼ Having a lack of interest in normal activities ◼ Showing less of your moods ◼ Avoiding places, people, or thoughts that remind you of the event ◼ Feeling like you have no future + Sx Cont. 3. Arousal ◼ Difficulty concentrating ◼ Startling easily ◼ Having an exaggerated response to things that startle you ◼ Feeling more aware (hypervigilance) ◼ Feeling irritable or having outbursts of anger ◼ Having trouble falling or staying asleep + Signs and tests ◼ There are no tests that can be done to diagnose PTSD. The diagnosis is made based on certain symptoms. ◼ In ◼ In PTSD, symptoms are present for at least 30 days. ASD, symptoms will be present for a shorter period of time. + Treatment ◼ Treatment can help prevent PTSD from developing after a trauma. A good social support system may also help protect against PTSD. ◼ If PTSD does occur, a form of treatment called “desensitization” may be used. ◼ This treatment helps reduce symptoms by encouraging you to remember the traumatic event and express your feelings about it. ◼ Over time, memories of the event should become less frightening. Discussion: The Instant Effects of Acute Stress Disorder & PTSD Mechanisms

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Support groups, where people who have had similar experiences share their feelings, may also be helpful. + Tx cont. People with PTSD may also have problems with: ◼ Alcohol or other substance abuse ◼ Depression ◼ Related medical conditions ◼ **Survivor’s Guilt** ◼In most cases, these problems should be treated before trying desensitization therapy. ◼Medicines that act on the nervous system can help reduce anxiety and other symptoms of PTSD. Antidepressants, including selective serotonin reuptake inhibitors (SSRIs), can be effective in treating PTSD. Other anti-anxiety and sleep medicines may also be helpful. ◼ Long-Term Crisis Reaction – a condition that occurs when victims do not suffer from PTSD, but may reexperience feelings of the crisis reaction when certain events trigger the recollection of the trauma to their lives ◼ Other Mental Disorders ◼ Depression ◼ Substance Abuse ◼ Other Effects ◼ Different victims of the same crime suffer different reactions to that crime, and conversely, victims of different crimes may suffer similar reactions ◼ Traumatic ◼ May be Incident Stress a consequence that victim service providers suffer as a result of exposure to catastrophic events, severely injured children or adults, dead bodies or body parts, or the loss of colleagues.

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May experience physical, cognitive, emotional or behavioral symptoms + What Is Stress? Stress •External demands placed on an organism •Organism’s internal biological and psychological responses to such demands + Stress and the DSM Stress and DSM •Significant component of multiple DSM diagnostic categories •Emphasized in Axis IV of DSM + Factors Creating Predisposition to Stress + Characteristics of Stressors Severity Chronicity Key characteristics of stress involve: Timing Degree of impact Level of expectation Controlability + Characteristics of Stressors Life changes Crises Perception of benefits + Stress and the Stress Response Two of body’s systems respond when stressor is perceived • Sympathetic-adrenomedullary (SAM) system (fight or flight) • Hypothalamic-pituitary adrenocortical (HPA)(cortisol production) + Biological Costs of Stress Allostasis •Is process of adaptation or achieving stability through change •Results in wear and tear on body + The Mind-Body Connection Psychoneuroimmunology • Study of interaction between nervous system and immune system + The Mind-Body Connection True or False? Stress may cause overall vulnerability to disease. + Stress, Depression, and the Immune System Depression •Associated with compromised immune function beyond stressors that precipitated depression + Stress and Physical Health Many psychological factors can affect relationship between stress and health

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•Optimism •Negative affect + Cardiovascular Disease Study in this area includes: Hypertension Coronary heart disease Risk and causal factors + Hypertension Hypertension involves persisting systolic and diastolic blood pressure Chronic hypertension and disease Hypertension and ethnicity Hypertension and anger management + Treatment of Stress-Related Physical Disorders Biological interventions Psychological interventions + Biological Interventions Antidepressant medications Aspirin or other anticoagulants Lipid-lowering medications Surgical procedures + Psychological Interventions Biofeedback Emotional disclosure Relaxation and meditation Cognitivebehavior therapy + Psychological Reactions to Stress Adjustment disorder Some DSM disorders are triggered by exposure to stress Posttraumatic stress disorder + Adjustment Disorder ◼ Maladaptive response to common stressor occurring within 3 months of stressor. ◼ Many stressors can lead to adjustment disorder. Can you think of any of these stressors? + Posttraumatic Stress Disorder Definition Causes Clinical description + Prevalence of PTSD in General Population ◼ Lifetime prevalence rate in the U.S. is 6.8% ◼ Higher rates in women despite finding that men are more likely to be exposed to traumatic events: In women, 9.7%, In men, 3.6% What contributes to this gender difference? + Rates of PTSD After Exposure to Specific Stressors Military combat Prisoner of war, concentration camp, and torture experience Traumas caused by human intent Accidents or natural disasters + Causal Factors in Posttraumatic Stress Disorder True or false? Not everyone exposed to a trauma will develop PTSD! + Causal Factors in Posttraumatic Stress Disorder Individual risk factors Nature of trauma Sociocultural risk factors Causal factors may include: + Individual Risk Factors How many can you name?

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+ ◼ Being ◼ Low female levels of social support ◼ Neuroticism ◼ Preexisting ◼ Family anxiety or depression history of anxiety or depression ◼ Substance abuse ◼ Appraisals soon after trauma + Individual Risk Factors High cognitive ability (IQ) may lower risk of PTSD Biological differences may play a role in likelihood of developing PTSD + ◼ Biological differences of developing PTSD ◼ Hormone levels ◼ Genetics ◼ Size of hippocampus may play a role in likelihood + Prevention and Treatment of Stress Disorders Psychological debriefing Prevention and treatment of stress disorders Challenges in studying crisis victims Trauma and physical health + Prevention Advanced preparation of stressor •Military service •Medical procedures •Relationship termination + Treatment for Stress Disorders Approaches to treatment include: •Telephone hotlines •Psychological first aid •Crisis intervention + Psychological Debriefing Strategies for relief of PTSD symptoms •Critical Incident Stress Debriefing •Medications •Cognitive-behavioral treatments + Challenges in Studying Crisis Victims Challenges Traumatic events cannot be predicted or controlled by researchers Variables of interest are difficult to assess Funding can be difficult to obtain + Trauma and Physical Health Relatively new area for physical research Studies indicate that trauma is bad for body as well as mind + Unresolved Issues What kinds of events should qualify as “traumatic”? What kinds of symptoms should be viewed as indicators of PTSD? How can the upcoming DSM-5 definition of PTSD be improved? + Discussion: The Instant Effects of Acute Stress Disorder & PTSD Mechanisms

◼ Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007;(3):CD003388. ◼ Hetrick SE, Purcell R, Garner B, Parslow B. Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2010;(7):CD007316. ◼ Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Early psychological interventions to treat acute traumatic stress symptoms.Cochrane Database Syst Rev. 2010;(3):CD007944. ◼ Gilbertson MW, Orr SP, Rauch SL, Pitman RK. Trauma and posttraumatic stress disorder. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 34. PRINCIPLES OF TRAUMA THERAPY SECOND EDITION DSM-5 UPDATE Praise for Principles of Trauma Therapy, 2nd edition Briere and Scott have taken a solid, powerful first edition and made it even more indispensable.

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Their deep understanding of the nature of this work, including the ways in which the therapist’s own experiences and history are activated by engagement with trauma survivors, comes through in a volume that is both clinically wise and scientifically informed. I particularly appreciate the new chapter on mindfulnessbased approaches to working with trauma, as well as the authors’ careful attention to issues of ethics in practice. This will be required reading for trainees at my clinic. —Laura S Brown, PhD ABPP, Director, Fremont Community Therapy Project, Past President, American Psychological Association Division of Trauma Psychology This book provides a deeply human, highly informative resource in the psychology of trauma. The principles set forth are guided by an excellent synthesis of the research literature along with a deep appreciation of clinical realities. This is one of the few books that are essential reading for clinicians working with trauma patients. —Marylene Cloitre, PhD, National Center for PTSD, and Professor of Psychiatry and Child & Adolescent Psychiatry, New York University Langone Medical Center Briere and Scott have made another remarkable contribution to the treatment of trauma with their extensively revised and updated book. The first edition of this book is already a classic, and the second edition offers an up-to-date compendium on trauma, its various manifestations, and its treatment. It includes attention to the most contemporary treatment applications, from which it draws broadly on the emerging neuroscience and clinical literature. It is noteworthy in terms of the empathy and compassion directed towards the traumatized client and applies principles of mindfulness to both client and therapist. A stellar accomplishment!

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—Christine A. Courtois, PhD, ABPP, Psychologist, Private Practice, Courtois & Associates, PC, Washington,DC, Author: Healing the Incest Wound: Adult Survivors in Therapy (Revised Edition), Recollections of Sexual Abuse: Treatment Principles and Guidelines, Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (with Julian Ford) This text is quite simply the best overview of trauma treatment that I have ever read. It combines clinical sophistication with compassion and evenhanded speculation about research trends to create a final product that is unrivaled in the literature. I will make it a goal to encourage every student and colleague that I have to read this book. —Constance Dalenberg, PhD, Director, Trauma Research Institute, Alliant International University, San Diego; Author: Countertransference and the Treatment of Trauma Briere and Scott have a new comprehensive text that provides state-of-the-art information on the assessment and treatment of trauma. This is essential reading for both experienced trauma therapists and those who are new to the field. Trauma treatment continues to evolve, as exemplified by the authors’ attention to innovative affect regulation and mindfulness interventions. —Victoria Follette, PhD, Foundation Professor, University of Nevada, Reno Briere and Scott have admirably updated what already was a remarkably thorough and clinically savvy clinician’s guide. By addressing a wide range of trauma-related symptoms, problems, and disorders, and offering evidence-based principles and tactics for assessment, psychotherapy, and pharmacological treatment, this volume provides an invaluable resource for every clinician who treats adults with posttraumatic disorders. Bravo! —Julian D. Ford, PhD, Professor of Psychiatry, Graduate School Faculty, University of Connecticut Health Center The writers of this book have made a major contribution, providing great value for those looking to evaluate, treat, and teach others about trauma. It includes a careful, thoughtful approach to understanding both the diagnosis of trauma and, more importantly, the psychology of trauma patients. Discussion: The Instant Effects of Acute Stress Disorder & PTSD Mechanisms

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The section on Clinical Interventions is invaluable, including a careful description of what is known and unknown about the brain, and the potential benefits of psychiatric medication. I heartily recommend this book. —Marcia Kraft Goin, MD, PhD, Professor of Clinical Psychiatry, Keck School of Medicine, University of Southern California, Past President, American Psychiatric Association PRINCIPLES OF TRAUMA THERAPY A Guide to Symptoms, Evaluation, and Treatment SECOND EDITION DSM-5 UPDATE John N. Briere Catherine Scott University of Southern California, Keck School of Medicine FOR INFORMATION: Copyright © 2015 by SAGE Publications, Inc. SAGE Publications, Inc. All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. 2455 Teller Road Thousand Oaks, California 91320 E-mail: order@sagepub.com SAGE Publications Ltd. 1 Oliver’s Yard 55 City Road London EC1Y 1SP Printed in the United States of America Library of Congress Cataloging-in-Publication Data United Kingdom Briere, John. SAGE Publications India Pvt. Ltd. Principles of trauma therapy : a guide to symptoms, evaluation, B 1/I 1 Mohan Cooperative Industrial Area and treatment / John N. Briere, Catherine Scott, University of Mathura Road, New Delhi 110 044 Southern California, Keck School of Medicine. — Second edition, India DSM-5 update. SAGE Publications Asia-Pacific Pte. Ltd. pages cm. 3 Church Street Includes bibliographical references and index. #10-04 Samsung Hub Singapore 049483 ISBN 978-1-4833-5124-7 (pbk. : alk. paper)

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1. Post-traumatic stress disorder—Treatment. 2. Psychic trauma—Treatment. 3. Diagnostic and statistical manual of mental disorders. 5th ed. I. Scott, Catherine, 1968- II. Title. III. Title: Diagnostic and statistical manual of mental disorders, 5th edition, update. RC552.P67B7495 2015 616.85′21—dc23   2014000149 This book is printed on acid-free paper. Acquisitions Editor: Kassie Graves Production Editor: Laura Barrett Typesetter: C&M Digitals (P) Ltd. Proofreader: Laura Webb Indexer: Maria Sosnowski Cover Designer: Gail Buschman Marketing Manager: Shari Countryman 14 15 16 17 18 10 9 8 7 6 5 4 3 2 1 CONTENTS  Acknowledgments ix Introduction to the Second Edition, DSM-5 Update 1 PART I: TRAUMA, EFFECTS, AND ASSESSMENT 7 1. What Is Trauma? 9 2. The Effects of Trauma John N. Briere, Catherine Scott, and Janelle Jones 25 3. Assessing Trauma and Posttraumatic Outcomes 63 PART II: CLINICAL INTERVENTIONS 95 4. Central Issues in Trauma Treatment 97 5. Psychoeducation 125 6. Distress Reduction and Affect Regulation Training 133 7. Cognitive Interventions 153 8. Emotional Processing 165 9. Increasing Identity and Relational Functioning 197 10. Mindfulness in Trauma Treatment 215 11. Treating the Effects of Acute Trauma Janelle Jones, Heidi Ardern, John N. Briere, and Catherine Scott 231 12. Psychobiology and Psychopharmacology of Trauma Catherine Scott, Janelle Jones, and John N. Briere 259 13. Conclusions 331 Appendix 1: Initial Trauma Review-3 (ITR-3) 333 Appendix 2: Mindfulness-based Breath Training (MBBT) Protocol Hand-out 341 References 343 Index 413 About the Authors 427

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W  e thank Janelle Jones and Heidi Ardern for their written contributions to this second edition and for their colleagueship throughout its writing; Katherine Avila, Courtney Bancroft, Laura Brown, Marylene Cloitre, Christine Courtois, Constance Dalenberg, Victoria Follette, Julian Ford, Warren Garner, Natacha Godbout, Marcia Goin, Monica Hodges, Cheryl Lanktree, Marsha Runtz, Randye Semple, and Weiguo Zhu for their detailed reviews and suggestions (errors remain our own); and Erin Eadie and Manny Zetino for much appreciated technical assistance. Many thanks to Elisha Agee who helped update the 2nd edition to include changes from DSM-IV-TR to DSM-5. We are also very grateful to SAGE acquisitions editor Kassie Graves, for her continuing advice and patience in this and prior projects, as well as to SAGE production editor Laura Barrett and editorial assistant Elizabeth Luizzi. JB thanks Cheryl Lanktree for her love, sustenance, and collaboration; the Briere, Lanktree, and Manson extended families for refuge and good times; and Colin Dias, Anne Galbraith, Natacha Godbout, John Jimenez, David Kim, Sebastien Malette, and Marsha Runtz for their friendship and support during the writing process. CS would like to thank John Jimenez for love and support in all things, and her mother, Martha Ford Brady Petrou, who was, and remains, her inspiration. During the writing of this second edition, CS had a newborn baby on her lap. He made many contributions, often creating chaos on her computer screen. This book would not have been completed without the help and love of the people who cared for her son while she worked: Dr. Jorge and Mrs. Alicia Jimenez, Gail Gordon and Richard Drapkin, Shana Blake Hill, Margarita Nicolas, Laura Cortez, and Heidi Trinidad. ix INTRODUCTION TO THE SECOND EDITION, DSM-5 UPDATE T  he history of humankind is not only a story of art, science, and culture, but it is also about war, interpersonal violence, oppression, and a plet … Discussion: The Instant Effects of Acute Stress Disorder & PTSD Mechanisms