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Posttraumatic Stress Disorder (PTSD), Complex-postraumatic stress disorder (C-PTSD)

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Posttraumatic stress disorder is thought to be caused by childhood "traumaThe most fundamental effect of trauma is dissociation, so we define trauma as the event(s) that cause dissociation. {{Rp|75}} The original trauma in those with dissociative identity disorder was failure of secure attachment with a primary attachment figure in early childhood. {{Rp|83}}" that was never moved from the mind to the hippocampus of the brainThe brain is a approximately a 1300-gram organ containing 100-billion neurons. It is the control center of the central nervous system. The mind and brain are not the same thing. (see mind) The mind emerges out of interactions between the brain and relationships during the earliest years of childhood. Different child-parent attachment relationships form differing physiological responses, patterns for interpersonal relationship and how an individual views the world. {{Rp|9}} (see attachment) where it should have been processed. [4] When unprocessed trauma events build up and reach a certain point, then the individual's mind, followed by the the brain become overwhelmed due to the lack of communication between them. [4] When all communication stops them the person becomes overwhelmed. [4] [5] This results in a barrier dividing the ganglia of the personality that are affected by the unprocessed events and the part that the mind attempts to keep from being affected by it. [4] [6] This process is known as structural dissociation of the personality. [6] [7] [6] At this point the person then has posttraumatic stress disorder. [4] [6] It's unknown if childhood abuse plays a role, but it is well accepted that "childhood neglect" (which can be unintentional) is critical to the formation of this disorder. Some older ideas are that the cause could have been when a child is subjected to loss, constant pain or some other emotional distress that is not inflicted upon them. [8] When structural dissociation takes place, one distinct state and one less than distinct state are created, which along with other factors cause the disturbing symptoms experienced in those with posttraumatic stress disorder. [4] [6]

Complex PTSD

After an individual already has posttraumatic stress disorder and unprocessed trauma events continue to build up in the mind, and are not processed into memory"Memory is not a static thing, but an active set of processes." {{Rp|51}} "Our earliest experiences shape not only what we remember, but also how we remember and how we shape the narrative of our lives. Memory can be seen as the way the mind encodes elements of experience into various forms of representation. As a child develops, the mind begins to create a sense of continuity across time, linking past experiences with present perceptions and anticipations of the future." {{Rp|11}}, then a second less than distinct state can be created. At this point, the individual will experience far greater symptoms than they did before the extra state was made. Once an person has created their second less than distinct state, this disorder is hard to ignore. The less than distinct states will wreck havoc in an individuals life. Less than distinct states are parts of the personality that react and interact with unprocessed trauma events. [4] [6]

fMRIA type of neuroimaging. Neuroimaging is an approach that allows researchers to view areas of the brain that become active during behavioral events such as emotion, perception and cognition. It is part of the science of in psychophysiology. scans

When a fMRI scan is performed on an individual with posttraumatic stress disorder their distinct state is brightly lit up, and as soon as a "triggerA reactivating stimulus in trauma disorders. A stimulus in the present which is a reminder of a part of a traumatic [[memory]], which can cause the part of an individual that hold the trauma (EP) to feel as if it is reliving past trauma experience. {{Rp|166-186}} Also known as a trauma trigger." is introduced to the individual, that distinct state is immediately replaced by a small, dimly lit spot, which is the less than distinct state. This state responds to the trigger by causing undesirable symptoms such as flashbacks, exaggerated startle response, hyperarousalIncreased arousal response, which is a diagnostic criteria for PTSD. Symptoms include "hypervigilance, exaggerated startle, sleep disturbance, concentration difficulties and anger"{{Rp|82}} plus physical tension, and emotions include anxiety and fear, a feeling of "experiencing too much" {{Rp|3,40,213}}., anxiety, anger and so on. As the individual calms, the less than distinct state is replaced by the distinct state. What is happening is the brain and mind are miscommunicating back and forth. (See Structural Dissociation for in-depth information) It's the miscomunication between the mind and brain that are causing the symptoms. The brain can't understand what the mind is trying to say, so it sends out a signal, and depending on what that signal is, the person feels an array of symptoms. If the individual has complex-posttraumatic stress disorder, their two less than distinct states will show up on the fMRI scan in unison, and they confuse the brain even more, and in response to that confusion, the brain sends out signals causing enhanced symptoms. The individual is now highly distressed, with symptoms that are probably overwhelming, leaving the person unable to function well while the less than distinct states are in control. [4]

Dissociative boundariesA dissociative boundary separates dissociated states. {{See also | Amnesia}} and elaboration of states

The less than distinct states in posttraumatic stress disorder are basic and primitive when compared to the less than distinct states in the complex Dissociative Disorders: other specified dissociative disorder and dissociative identity disorder. In addition, the dissociative boundaries that are associated with each of the disorders are highly specific to the disorder and to each state they are associated with. At the most extreme end of the spectrum is dissociative identity disorder with states so elaborated they have their own way of being, and can even have different physiological characteristics. In this disorder you will find an individual who's dissociative boundaries are so phobic of each other that each of the states are isolated from the others in a number of ways that are not found in posttraumatic stress disorder. In dissociative identity disorder, one state could be literally blind, another deaf, another with an IQ of 70 and another could be a genius and none have any idea of what is going on. Posttraumatic stress disorder does not have the advantage of the highly dissociated boundaries, and so the symptoms are glaringly painful and obvious to the person with them. [4] [6]

In PTSD there is only one less than distinct state and one distinct state, and both stay conscious until a trigger causes the less than distinct state to respond, (flashbackA flashback is a reactivated traumatic memory experienced as intrusive thoughts, feelings, or images associated with past trauma, but lacking a sense of being from the past. {{Rp|30}} It is experienced by the state referred to as the EP. {{See also | Grounding techniques}}, fear, anxiety or other like symptom) and when it does the distinct state leaves consciousness. In the complex version of PTSD there are always two less than distinct states, and one distinct state. The less than distinct states are polarized, staying together, with both always conscious at the same time, but otherwise behave the same as simple PTSD. In "image B", this fMRI scan shows a distinct state switchingFull dissociation is when an alter switches with the alter currently in executive control, resulting in amnesia for that alter. (see executive control) {{Rp|4-6}} In full dissociation, there is complete amnesia between dissociated states, which is a {{Rp|228}} criteria for a diagnosis of dissociative identity disorder in the DSM-5. {{See also| Dissociation}} with an other distinct state, which is only possible in DID, because this is the only disorder with two or more distinct states. "Image A" shows three less than distinct states which are the parts that manage "unprocessed trauma," and react to it with vehement emotion. This is obviously an fMRI scan of DID since it shows there are two distinct states and three less than distinct states. In OSDD fMRI scans reveal only one distinct state is possible, and it switches with less than distinct states randomly, and the distinct state also switches in response to a "trigger." In contrast to DID, every single state can literally be conscious (lit up) at one time, but in response to a trigger, all but one state will leave consciousness, which is again in contrast with DID. BPD involves one distinct state and it's always conscious until the individual is in distress, and then two less than distinct states show up together, but unlike C-PTSD these less than distinct states do not take over consciousness. The distinct state always remains with them. There are no flashbacks or other symptoms caused from unprocessed trauma events in BPD like there are in all the other disorders mentioned so far, but there are other dissociative symptoms. [9] [6]

History of posttraumatic stress disorder

Posttraumatic stress disorder first become an official diagnosis in the DSM-III, which was published in 1980. [10] Prior to this the experience of posttraumatic stress was represented in both the DSMPublished by the American Psychiatric Association as the standard classification of mental disorders used by US mental health professionals. It consists of diagnostic classification, the diagnostic criteria sets, and descriptive text. The DSM-II listed multiple personality disorder as a symptom of hysterical neurosis, dissociative type. The DSM-III (1980) moved Multiple Personality Disorder from a symptom to its own disorder. The DSM-IV changed the name to dissociative identity disorder (1994) and the DSM-5 (May 2013) updated the listing to current standards. {{Rp|384}}-I, [11] [12] published in 1952, and the DSM-II, published in 1968. [13] Another diagnostic manual, the International Classification of Diseases (ICD) is produced by the World Health Organization, and originally focused on physical illness only, first including a section of mental disorders in the ICD-6 version, published in 1948.[14]

Diagnostic manuals

Diagnostic manuals like the DSM and ICD are not meant to be used to understand any mental disorderThe DSM-5 psychiatric manual defines this as "a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."{{Rp|20}}. Their intent is to give the minimum criteria needed to diagnose a disorder. The criteria listed here is paraphrased, as proper etiquette demands.

PTSD preSchool subtype

For children 6 years and younger the criteria is slightly different. This is included in the DSM-5 manual for children younger than six years. [15] The criteria for posttraumatic stress disorder needed to be slightly different from those for older children and adults because young children their cognitive and verbal expression capacities as still forming, so the criteria are more "developmentally sensitive" for preschool children. Some of these changes in wording include:

  • constricted play is an example of "diminished interest in significant activities"
  • social withdrawal or behavioral changes can indicate "feelings of detachmentCharacterized by distant interpersonal relationships and lack of emotional involvement {{Rp|24}} or estrangement"
  • extreme temper tantrums are now included with "irritability or outbursts of anger"
  • intrusive symptoms such as flashbacks and intrusive thoughts do not always manifest overt distress in preschool children, Scheeringa (2013) states that "while distressed reactions are common, parents also commonly reported no affect"a person's present emotional responsiveness, which can be inferred from facial expressions" including both the degree and range of expressive behavior. This can also be shown in tone of voice, hand and body movements. {{Rp| 6}} or what appeared to be excitement"
  • fewer avoidance symptoms are included because avoidance is internalized, and harder to detect by observation, for example in pre-verbal children

Research has shown preschool children with posttraumatic stress disorder do have impaired functioning across a range of domains, and both the diagnosis and impairment are stable over the longer-term. [1] Scheeringa and Zeanah (2008) studied posttraumatic stress disorder in 70 three to six-year old's directly effected by Hurricane Katrina. They found that children who stayed in New Orleans had significantly higher rates of posttraumatic stress disorder than children who were evacuated (62.5%, in comparison to 43.5%); of the children who did not develop posttraumatic stress disorder, none of them developed other mental disorders as a result of the trauma. The children had significantly higher rates of posttraumatic stress disorder than their caregivers, Scheeringa and Zeanah (2008) stated that "caregivers' rate of posttraumatic stress disorder was 35.6%, of which 47.6% was new post-Katrina". Caregivers' rate of posttraumatic stress disorderwas 35.6%, of which 47.6% was new post-Katrina.

Meiser-Stedman et al. (2008) studied children aged 2–6 years old, and aged 7–10 years old, after traumatic motor vehicle accidents. They found that parent's and children's reports of the traumatic experience had "poor agreement" between them, reflecting the fact that relying only on parent's reports of the trauma would lead to a lack of information for clinicians when assessing posttraumatic stress disorder, given the subjective nature of the experience. [2] Effective treatment for posttraumatic stress disorder in very young children includes cognitive behavioral therapy, long-term, relationally-based treatment (in cases of interpersonal violence), play therapy, eye movement desensitization and reprocessing (EMDRA valid psychotherapeutic approach, especially for treating trauma. ), and other forms of therapy, however, the methods of addressing trauma need to be developmentally-appropriate methods for the child's age.

DSM-5 adult PTSD criteria

DSM-5 was last updated May 2013
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 events(s) as it occurred to others.
  3. Learning that the traumatic events(s) occurred to a close family member or close friend. In cases of actual or threatened by death of a family member or friend, the events(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"interactions in which one person behaves in a violent, demeaning or invasive manner towards another person (e.g. child or partner)" ). This does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work related.
Presence of one (or more) of the following intrusionParts of the [[personality]] influence each other, whether they are aware of others or not. Any part may intrude on, and influence the experience of the part that is functioning in daily life, without taking full control of functioning. {{Rp|27}} In dissociative identity disorder and other disorders, dissociative symptoms are felt when one dissociated state intrudes into the experience of another. Intrusions occur in perceptions, ideas, wishes, needs, movements and behaviors. {{Rp|18}} In partial dissociation, amnesia is not present. {{Rp|228}} symptoms associated with the traumatic event(s) occurred:
  1. Recurrent, involuntary, and intrusive distressing effects from the unprocessed trauma events. In children older than 6, there may be frightening dreams without recognizable content.
  2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic events(s).
  3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the trauma 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). In children, trauma-specific reenactment may occur in play.
  4. Intense or prolonged psychological distress at exposure to internal or external clues that symbolize or resemble an aspect of the traumatic events.
  5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
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 unprocessed trauma events, 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).
Negative alterations in cognitions and mood"Pervasive and sustained emotion" which affects a person's perception of the world.{{Rp|6}} associated with the traumatic events(s), beginning or worsening after the traumatic event(s)
  1. Inability to remember an important aspect of the traumatic events(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
  2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," no one can be trusted," the world is completely dangerous, my whole nervousness system is permanently ruined.).
  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 (e.g., fear, horror, anger, guilt, or shame).
  5. Markedly diminished interest or participating in significant activities.
  6. Feelings of detachment or estrangement from others.
  7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
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"Excessive attention to and focus on all internal and external stimuli."{{Rp|26} A pattern presenting with fight or flight reactions is common in individuals with unprocessed trauma memories. {{Rp|217}} A PTSD symptom. Hypervigilance is an arousal symptom within PTSD and acute stress disorder.
  4. Exaggerated startle response
  5. Problems with concentration
  6. Sleep disturbances
Criteria B, C, D and E last more than 1 month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not attributable to the effects of a substance (e.g., medication, alcohol) or another medical condition.
Specify if with depersonalization
Specify if with derealization
Specify if with delayed expression [16]:272-274[15]:143-145

References

  1. ^ Meiser-Stedman R, Smith P, Glucksman E, Yule W, Dalgleish T: The posttraumatic stress disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents. Am J Psychiatry 2008; 165:1326–1337
  2. ^ a b c Scheeringa, Michael S.. Developmental Considerations for Diagnosing PTSD and Acute Stress Disorder in Preschool and School-Age Children. Am J Psychiatry, volume 165, issue 10, October 01, 2008, page 1237-1239. (doi:10.1176/appi.ajp.2008.08070974)
  3. ^ a b Scheeringa, Michael. PTSD: National Center for PTSD: PTSD for Children 6 Years and Younger. retrieved on 9 July, 2014
  4. ^ a b c d e f g h i Lanius, Ulrich (2014) (coauthors: Sandra L. Paulsen, Frank M. Corrigan). . New York:Springer Publishing Company. 10: 0826106315.
  5. ^ Siegel, Daniel (2012). . Guilford press. 13: 978-1462503902.
  6. ^ a b c d e f g h Vanderhart, Onno (2006) (coauthors: Nijenhuis, Ellert; Steele, Kathy). . New York:Norton. 13: 978-0393704013.
  7. ^ Nijenhuis, Ellert; van der Hart, Onno (2011). Dissociation in Trauma: A New Definition and Comparison with Previous Formulations. Journal of Trauma & Dissociation, volume 12, issue 4, 2011. (doi:10.1080/152992)
  8. ^ Courtois, Christine (2012) (coauthors: Ford, Julian). . The Guilford Press. .
  9. ^ Schlumpf, YR; Reinders, AATS, Nijenhuis, ERS, Luechinger, R, van Osch, MJP, et al. (2014). Dissociative Part-Dependent Resting-State Activity in Dissociative Identity Disorder: A Controlled fMRI Perfusion Study. PLoS ONE, volume 9, issue 6, 2014. (doi:10.1371/journal.pone.0098795)
  10. ^ Wilson, John P.. The historical evolution of PTSD diagnostic criteria: From freud to DSM-IV. Journal of Traumatic Stress, volume 7, issue 4, page 681–698. (doi:10.1007/BF02103015)
  11. ^ American Psychiatric Association: Diagnostic and Statistical Manual of Mentral Disorders. (First edition) Washington, D.C. 1952
  12. ^ Blair Simpson, Helen (2010) (coauthors: Neria, Yuval, Lewis-Fernández, Roberto (Eds)). Anxiety Disorders: Theory, Research and Clinical Perspectives edited by Helen Blair Simpson, Yuval Neria, Roberto. Cambridge Illustrated University Press..
  13. ^ The Committee on Nomenclature and Statistics of the American Psychiatric Association, (1968). DSM-II DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (Second Edition). American Psychiatric Association.
  14. ^ Brett, Elizabeth A. (1996) (coauthors: van der Kolk, Bessel A., McFarlane, Alexander C., Weisaeth, Lars (Eds.)). The classification of Posttraumatic stress disorder. In Traumatic Stress the Effects of Overwhelming Experience on Mind, Body, and Society. New York:Guilford Publications..
  15. ^ a b American Psychiatric Association, (2013). . APA..
  16. ^ American Psychiatric Association, (2013). . Washington, D.C:American Psychiatric Association.541.
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