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Psychological and Physiological Trauma Research
Seize Your Journeys
_______________________ Traumatic stress is found in many competent, healthy, strong, good people. No one can completely protect themselves from traumatic experiences. Many people have long-lasting problems following exposure to trauma. Up to 8% of persons will have PTSD at some time in their lives. People who react to traumas are not going crazy. What is happening to them is part of a set of common symptoms and problems that are connected with being in a traumatic situation, and thus, is a normal reaction to abnormal events and experiences. Having symptoms after a traumatic event is NOT a sign of personal weakness. Given exposure to a trauma that is bad enough, probably all people would develop PTSD. By understanding trauma symptoms better, a person can become less fearful of them and better able to manage them. By recognizing the effects of trauma and knowing more about symptoms, a person will be better able to decide about getting treatment. _______________________
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Circadian Rhythm Sleep Disorder (formerly Sleep-Wake Schedule Disorder) Diagnostic Features “The essential feature of Circadian Rhythm Sleep Disorder is a persistent or recurrent pattern of sleep disruption that results from a mismatch between the individual’s endogenous circadian sleep-wake system on the one hand, and exogenous demands regarding the timing and duration of sleep on the other (Criterion A). In contrast to other primary Sleep Disorders, circadian Rhythm Sleep Disorder does not result from the mechanisms generating sleep and wakefulness per se. As a result of this circadian mismatch, individuals with this disorder may complain of insomnia at certain times during the day and excessive sleepiness at other times, with resulting impairment in social, occupational, or other important areas of functioning or marked subjective distress (Criterion B). The sleep problems are not better accounted for by other Sleep Disorders or other mental disorders (Criterion C) and are not due to the direct physiological effects of a substance or a general condition (Criterion D). The diagnosis of Circadian Rhythm Sleep Disorder should be reserved for those presentations in which the individual has significant social or occupational impairment or marked distress related to the sleep disturbance. Individuals vary widely in their ability to adapt to circadian changes and requirements. Many, if not most, individuals with circadian-related symptoms of sleep disturbance do not seek treatment and do not have symptoms of sufficient severity to warrant a diagnosis. Those who prevent for evaluation because of this disorder are most often troubled by the severity or persistence of their symptoms. For example, it is not unusual for shift workers to present for evaluation after falling asleep while on the job or while driving. The diagnosis of Circadian Rhythm Sleep disorder rests primarily on the clinical history, including the pattern of work, sleep, naps, and ‘free time.” The history should also examine past attempts at coping with symptoms, such as attempts at advancing the sleep-wake schedule in delayed Sleep Phase Type. Prospective sleep-wake diaries or sleep charts are often a useful adjunct to diagnosis. Subtypes Delayed Sleep Phase Type. This type of Circadian Rhythm Sleep disorder results from an endogenous sleep-wake cycle that is delayed relative to the demands of society. Measurement of endogenous circadian rhythms (e.g., core body temperature) reflects this delay. Individuals with this subtype (“night owls”) are hypothesized to have an abnormally diminished ability to phase-advance sleep-wake hours (i.e., to move sleep and wakefulness to earlier clock times). As a result, these individuals are ‘locked in” to habitually late sleep hours and cannot move these sleep hours forward to an earlier time. The circadian phase of sleep is stable: individuals will fall asleep and awaken at consistent, albeit delayed, times when left to their own schedule (e.g., on weekends or vacations). Affected individuals complain of difficulty falling asleep at socially acceptable hours, but once sleep is initiated, it is normal. There is no concomitant difficulty awakening at socially acceptable hours (e.g., multiple alarm clocks are often unable to arouse the individual). Because many individual with this disorder will be chronically sleep deprived, sleepiness during the desired wake period may occur. Jet Lag Type. In this type of Circadian Rhythm sleep Disorder, the endogenous circadian sleep-wake cycle is normal and the disturbance arises from conflict between the pattern of sleep and wakefulness generated by the circadian system and the pattern of sleep and wakefulness required by a new time zone. Individuals with this type complain of a mismatch between desired and required hours of sleep and wakefulness. The severity of the mismatch is proportional to the number of time zones traveled through, with maximal difficulties often noted after traveling through eight or more time zones in less than 24 hours. Eastward travel (advancing sleep-wake hours) is typically more difficult for most individuals to tolerate than westward travel (delaying sleep-wake hours). Shift Work Type. In this type of Circadian Rhythm Sleep Disorder, the endogenous circadian sleep-wake cycle is normal and the disturbance arises from conflict between the pattern of sleep and wakefulness generated by the circadian system and the desired pattern of sleep and wakefulness required by shift work. Rotating-shift schedules are the most disruptive because they force sleep and wakefulness into aberrant circadian positions and prevent any consistent adjustment. Night- and rotating-shift workers typically have a shorter sleep duration and more frequent disturbances in sleep continuity than morning and afternoon workers. Conversely, there may also be sleepiness during the desired wake period, that is, in the middle of the night work shift. The circadian mismatch of the Shift Work Type is further exacerbated by insufficient sleep time, social, and family demands, and environmental disturbances (e.g., telephone, traffic noise) during intended sleep times. Unspecified Type. This type of Circadian Rhythm Sleep Disorder should be indicated if another pattern of circadian sleep disturbance (e.g., advanced sleep phase, non-24-hour sleep-wake pattern, or irregular sleep-wake pattern) is present. An “advanced sleep phase pattern” is the analog of Delayed Sleep Phase Type, but in the opposite direction: individuals complain of an inability to stay awake in the evening and spontaneous awakening in the early morning hours. “Non-24-hour sleep-wake pattern” denotes a free-running cycle: the sleep-wake schedule follows the endogenous circadian rhythm period of approximately 24-25 hours despite the presence of 24-hour time cues in the environment. In contrast to the stable sleep-wake pattern of the Delayed or advanced sleep phase types, these individuals’ sleep-wake schedules become progressively delayed relative to the 24-hour clock, resulting in a changing sleep-wake pattern over successive days. “Irregular sleep-wake pattern” indicated the absence of an identifiable pattern of sleep and wakefulness. Associated Features and Disorders Associated descriptive features and mental disorders. In Delayed Sleep Phase Type, individuals frequently go to bed later and wake up later on weekends or during vacations, with a reduction in sleep-onset difficulties and difficulty awakening. They will typically give many examples of school, work, and social difficulties arising from their inability to awaken at socially desired times. If awakened earlier than the time dictated by the circadian timekeeping system, the individual may demonstrate “sleep drunkenness” (i.e., extreme difficulty awakening, confusion, and inappropriate behavior). Performance often also follows a delayed phase, with peak efficiency occurring in late-evening hours. Jet Lag and Shift Work Types may be more common in individuals who are “morning types.” Performance is often impaired during desired waking hours, following the pattern that would be predicted by the underlying endogenous circadian rhythms. Jet lag is often accompanied by nonspecified symptoms (e.g., headache, fatigue, indigestion) that relate to travel conditions, such as sleep deprivation, alcohol and caffeine use, and decreased ambient air pressure in airplane cabins. Dysfunction in occupational, family, and social roles is often observed in individuals who have difficulty coping with shift work. Individuals with any Circadian Rhythm Sleep Disorder may have a history of alcohol, sedative-hypnotic, or stimulant use resulting from attempts to control their inappropriately phased sleep-wake tendencies. The use of these substances may in turn exacerbate the Circadian Rhythm Sleep Disorder. Delayed Sleep Phase Type has been associated with schizoid, schizotypical, and avoidant personality features, particularly in adolescents. “Non-24-hour sleep-wake pattern” and “irregular sleep-wake pattern” have also been associated with these same features. Jet Lag and Shift Work Type may precipitate or exacerbate a Manic or Major Depressive Episode or an episode of a Psychotic Disorder. Diagnostic and Statistical Manual of Mental Disorders DSM-IV. 1994. 4th ed. Washington, D.C.: American Psychiatric Association. ________________ Secure Attachments as a Defense Against Trauma “All people mature and thrive in a social context that has profound effects on how they cope with life’s stresses. Particularly early in life, the social context plays a critical role in suffering an individual against stressful situations, and in building the psychological and biological capacities to deal with further stresses. The primary function of parents can be thought of as helping children modulate their arousal by attuned and well-timed provision of playing, feeding, comforting, touching, looking, cleaning, and resting—in short, by teaching them skills that will gradually help them modulate their own arousal. Secure attachment bonds serve as primary defenses against trauma-induced psychopathology in both children and adults (Finkelhor & Browne, 1984). In children who have been exposed to severe stressors, the quality of the parental bond is probably the single most important determinant of long-term damage (McFarlane, 1988).” van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds. 1996. Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York and London: Guilford Press. .p. 185Affect Dysregulation in Traumatized Individuals “As children mature, they gradually become less vulnerable to over-stimulation and learn to tolerate higher levels of excitement. Over time, their need for physical proximity to their primary caregivers to maintain comfort decreases, and children start spending more time playing with their peers and with their fathers (Field, 1985). Secure children learn how to take care of themselves effectively as long as the environment is more or less predictable; simultaneously, they learn how to get help when they are distressed. In contrast, avoidant children learn how to organize their behavior effectively under ordinary conditions, but they remain unable to communicate or interpret emotional signals. In other words, they know how to handle cognition, but not affect (Crittenden, 1994 Cole and Putnam (1992) have proposed that people’s core concepts of themselves are defined to a substantial degree by their capacity to regulate their internal states and by their behavioral responses to external stress. The lack of development, or loss, of self-regulatory processes in abused children leads to problems with self-definition: (1) disturbances of the sense of self, such as a sense of separateness, loss of autobiographical memories, and disturbances of body image; (2) poorly modulated affect and impulse control, including aggression against self and others; and (3) insecurity in relationships, such as trouble functioning in social settings; they tend either to draw attention to themselves or to withdraw from social interactions. Thus, they tend to display either angry, threatening, fearless, acting-out behavior or meek, submissive, fearful, incompetent behavior. Problems in articulating cause and effect make it hard for them to appreciate their own contributions to their problems and set the stage for paranoid attributions.” van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds. 1996. Traumatic stress: The effects o overwhelming experience on mind, body, and society. New York and London: Guilford Press. .p. 187Manifestations of the Absence of Self-Regulation “The lack or loss of self-regulation is possibly the most far-reaching effect of psychological trauma in both children and adults. The DSM-IV field trials for PTSD clearly demonstrated that the younger the age at which the trauma occurred, and the longer its duration, the more likely people were to have long-term problems with the regulation of anger, anxiety, and sexual impulses (van der Kolk, Roth, Pelcovitz, & Mandel, 1993). Pitman, Orr, and Shalev (1993) have pointed out that in PTSD, hyperarousal goes well beyond simple conditioning. The fact that the stimuli that precipitate emergency responses are not conditioned enough and that many triggers not directly related to the traumatic experience may precipitate extreme reactions is merely the beginning of the problem. Loss/lack of self-regulation may be expressed in many different ways: as a loss of ability to focus on appropriate stimuli; as attentional problems; as an inability to inhibit action when aroused (loss of impulse control); or as uncontrollable feelings of rage, anger, or sadness. The results of a study by McFarlane, Weber, and Clark (1993) of event-related potentials in people with PTSD illustrate these various effects.” Van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds. 1996. Traumatic stress: The effects o overwhelming experience on mind, body, and society. New York and London: Guilford Press. .p. 187Self-Mutilation Eating Disorders Substance Abuse Dissociation __________________ Substance Abuse Features “The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances. In order for an Abuse criterion to be met, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent. There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems (Criterion A). Unlike the criteria for Substance Dependence, the criteria for Substance Abuse do not include only the harmful consequences of repeated use. A diagnosis of Substance Abuse is preempted by the diagnosis of Substance Dependence if the individual’s pattern of substance use has ever met the criteria for Dependence for that class of substances (Criterion B). Although a diagnosis of Substance Abuse is more likely in individuals who have only recently started taking the substance, some individuals continue to have substance-related adverse social consequences over a long period of time without developing evidence of Substance Dependence. The category of Substance Abuse does not apply to caffeine and nicotine. The term abuse should be applied only to a pattern of substance use that meets the criteria for this disorder; the term should not be used as a synonym for “use”,” misuse,” or “hazardous use.” The individual may repeatedly demonstrate intoxication or other substance-related symptoms when expected to fulfill major role obligations at work, school, or home (Criterion A1). There may be repeated absences or poor work performance related to recurrent hangovers. A student might have substance-related absences, suspensions, or expulsions from school. While intoxicated, the individual may neglect children or household duties. The person may repeatedly be intoxicated in situations that are physically hazardous (.e.g., while driving a car, operating machinery, or engaging in risky recreational behavior such as swimming or rock climbing) (Criterion A2). There may be recurrent substance-related legal problems (e.g., arrests for disorderly conduct, assault and battery, driving under the influence) (Criterion A3). The person may continue to use the substance despite a history of undesirable persistent or recurrent social or interpersonal consequences (e.g., marital difficulties or divorce, verbal or physical fights) (Criterion A4). Criteria for Substance Abuse A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifestd by one (or More) of the following, occurring within a 12-month period: (1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) (2) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) (3) Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) (4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., personal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) B. The symptoms have never met the criteria for Substance Dependence for this class of substance.” (p. 198-199) American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association.___________________
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EMDR-DID-PTSD (defined) EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach.During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session.Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Although eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced.In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com___________________ Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be re-experienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)." ________________ Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders . 2000. 4th ed. Washington, D.C.: American Psychiatric Association.__________________
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Life Cycle Journeys Contents
Table of Contents
Bipolar Disorder and Trauma
Title: Psychological Trauma and the Borderline Personality. |
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