What is post-traumatic stress disorder (PTSD)? - Chapter 16

What is this chapter about?

Experiencing a traumatic event can lead to several psychological problems, such as anxiety, depression, behavioural problems, substance abuse or post-traumatic stress disorder (PTSD). According to the DSM-IV-TR, one can be diagnosed with post-traumatic stress disorder (PTSD) if, as a result of such an event, there are persistent symptoms for at least one month (because most people spontaneously recover within about a month). For example:

• Re-experiencing the traumatic event (for example through flashbacks or nightmares).
• Avoiding the things that remind the child of the trauma or emotional dulling, in which the child generalizes the triggers.
• Increased physiological arousal (difficulty falling asleep or staying asleep, getting angry very fast, difficulty concentrating, being extra alert).

Young children often experience less of symptoms 1 and 2 as described above. That is why there are special criteria for young children. These criteria focus more on observing and reporting behavioural symptoms by people who regularly interact with the child.

82% of young people suffering from PTSD have a comorbid disorder. There are three possible causes that explain this high comorbidity:

1. Some factors – such as poor family function or unsafe attachment style – are risk factors for developing both PTSD and other psychological problems.
2. Comorbid psychological problems can be secondary to PTSD (for example: being depressed due to PTSD). This is supported by the fact that the comorbid disorder often improves through the PTSD treatment.
3. The comorbid disorder can sustain the PTSD.

What does the cognitive model of PTSD mean?

Meiser-Stedman's cognitive model of PTSD in children and adolescents (2002) shows how PTSD develops, how it is sustained, and how interventions can help. Problems associated with PTSD are often persistent because of the nature of the traumatic memory, or because of the significance attributed to the event, or by both.

Brain and colleagues (1996) introduced the term VAMs – verbally accessible memories, to refer to memories of normal autobiographical events. VAMs are coherent reminders and can be called up on purpose, can be updated (or manipulated) with new information and involve concepts of time and place. In a situation of extreme stress, the balance shifts from a conceptual to a perceptual processing, making the memory qualitatively different from a VAM. Such memories are called SAMs – situationally accessible memories, and are stored in terms of incoherent images, sounds, smells, tastes and physical sensations. SAMs are easily triggered and brought to consciousness when the person does not want these SAMs. Memories are often deliberately suppressed. SAMs don't involve the concepts of time and place that makes it feel like it's happening right now (so it feels more like a memory). The development of PTSD is associated with a vicious circle in which the memory imposes itself, followed by stress and a deliberate suppression of the memory, while this suppression of the memory naturally leads to the memory being more frequently imposed.

There is also an ‘adopted world’ in which there are assumptions or beliefs about three things: the world (how it's supposed to work), about other people and about yourself. These assumptions are often unconscious, unspoken and are often automatic. Through these glasses, events are observed and given meaning. After a trauma, many people revise their "adopted world", so that there is a good fit between this and the traumatic event: something Horowitz (1986) calls the ‘completion tendency’. In this way, previous, helpful assumptions are replaced by negative beliefs. For example, in the case of an attacked teenager:

• The world is safe, except at night -- the world is unsafe.
• Most people are good at heart, only some are not -- others are bad.
• I'm strong and safe -- I'm vulnerable.

This can also be incorporated into a cognitive behavioural formulation, in which the four systems: thoughts ("when I go out, I am attacked), feelings (anxiety), physical reaction (arousal) and behavior (staying indoors) interact, and – can be strengthened by the family that encourages him/her to stay indoors – lead to the three beliefs as above (the world is unsafe, others are bad, I am vulnerable).

The vicious circle regarding "vicarious avoidance" is as follows: the parents think that talking about the trauma will make the situation worse, so they do not bring it up. The result is that the child will think that no one wants to talk about it, and therefore does not bring it up himself. While the parents assume that everything is okay because the child does not bring it up, the SAM remains unprocessed. This avoidance limits the child's ability to process the memory properly and to re-evaluate trauma-based beliefs.

How does the analysis of PTSD symptoms take place?

If a child has experienced interpersonal trauma, it is difficult for the child to trust others (such as the therapist). A careful formulation should be made so that 1) the child and the parents learn to understand the stress and problems, 2) the comorbid problems are mapped, and 3) there is a guide to the intervention. If a comorbid depression maintains the avoidant symptoms of PTSD, then the depression may need to be treated first. If symptoms of depression are the result of PTSD, then the PTSD must first be treated.

Sometimes there is a court case: it can make the situation more complex, but does not have to rule out treatment!

Questionnaires and structured interviews are useful additional sources of information in order to evaluate certain areas in a systematic and quantitative way.

How can PTSD be treated?

Because of its high comorbidity, PTSD cases are often very complex. Developing, revising and implementing a formulation and intervention plan is necessary for effective CBT treatment. This formulation is a "story" in which the different sources of information about the person, his/her experiences and the problem (how did it arise and what sustains it) connect. It's not just a list of factors, but it explains how these factors affect the problem. The wording also reveals specific targets for the intervention, resulting in a direct intervention plan arising from this formulation. According to Persons (1989), sharing the wording with the client and the parents has a number of positive effects and purposes: making sure that it is a good fit with the client's experience, communicating that the therapist has listened carefully, declaring that their reactions to the traumatic event are natural and that there is not something "fundamentally wrong" with them, and explaining the rationale for the intervention that will increase motivation. The wording can be explained verbally, but often help diagrams. See p. 1. 244 for a template for a formulation. When someone close to the child has died and this is part of the experienced trauma, the trauma of death and other PTSD symptoms can hinder the grieving process. In this case, children must first be guided in processing the experience of death, before they can process their loss.

An effective intervention contains a combination of three components (Ehlers & Clark, 2000): reducing avoidant strategies, changing the traumatic event (reviving) to form a coherent narrative of the event (narrative exposure), and developing a meaning that is both true and useful (cognitive restructuring). It is important that the child and the parents are well prepared for this, given the intensity of the treatment. First of all, there must be stability and security, and systematic work must be done. Both of these have an impact on each other and serve together as the basis for a healthy therapeutic context/relationship in which the therapist is calm, confident, clear and collaborative. Finally, the therapeutic relationship serves as a platform for the development of individual sources. Individual sources include learning to regulate emotions using emotional recognition, self-talk, relaxation techniques and problem-solving skills. Only then one can progress to the other three components:

1. Reduce avoidant (coping) behavior. Avoidant behavior is the most important perpetuating factor in most anxiety disorders, including PTSD. This avoidance often generalizes enormously. Spending one or more sessions on the child gradually in vivo – in the flesh – exposing a dreaded situation (therapist and child or therapist, child and parents) is often the best remedy.
2. Narrative exposure. The purpose of this component is to create a coherent, verbal reminder of the experience, by evoking the memory in a safe therapeutic context. To process a traumatic memory, it must be properly and consciously revived and thought through, as a story with a beginning and an end. This is not a popular part of the treatment, but by explaining why this works, motivation can increase. There are several metaphors that you can use for this. An example of this is the chocolate factory metaphor: a chocolate factory uses different ingredients to make a chocolate bar, after which the ingredients are listed on the outside. This can only be done if all ingredients are in balance and ready to be processed. We know what each bar (memory) means because of the words on the outside (the story about all feelings, thoughts, touches etc.): we experience it from a distance. Two other metaphors are the wardrobe metaphor and the paper waste bin metaphor (see page 248 and 249). There are several methods to use: drawings or dolls, but also writing are good ways to revive the child's memory. You can also share an A4 in four quadrants: "my life before the event", "the worst part of it", "my life since the event" and "my wishes for the future". All in all, the sensory elements should become less clear than the words, and the story prevails.
3. Cognitive restructuring: the same cognitive restructuring methods used in other disorders can also be used for PTSD.

As for its effectiveness, this extract has already stated that there is a lot of empirical support for the effectiveness of TF-CBT.

Experiencing a traumatic event can lead to several psychological problems, such as anxiety, depression, behavioural problems, substance abuse or post-traumatic stress disorder (PTSD). According to the DSM-IV-TR, one can be diagnosed with post-traumatic stress disorder (PTSD) if, as a result of such an event, there are persistent symptoms for at least one month (because most people spontaneously recover within about a month).