June Spotlight-Post TraumaticStress Disorder

    (Review of April, 2023 Training delivered to the Mental Health team by Dr. Christopher Smith)

Post Traumatic Stress Disorder may occur after exposure to actual or threatened death, serious injury or violence. The person may directly experience a traumatic event, witness an event as it occurred to others, or learn that a traumatic event occurred to a close family member or close friend. Traumatic Events may include serious accidents, physical or sexual assault, or abuse (e.g., childhood abuse, domestic violence). After the traumatic event, the person may experience recurrent, involuntary, and intrusive memories of the event(s), distressing dreams related to the event(s), dissociative reactions (e.g., flashbacks), or intense or prolonged psychological distress or physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

PTSD often results in persistent avoidance of stimuli associated with the traumatic events, including efforts to avoid distressing memories, thoughts, or feelings, or external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories. In addition, PTSD is often accompanied by negative alterations in cognition and mood associated with the traumatic event(s), including the
inability to remember the event(s) (dissociative amnesia); 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”); persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the
individual to blame him/herself or others; persistent negative emotional states (e.g., fear, horror, anger, guilt, or shame); markedly diminished interest or participation in
significant activities; feelings of detachment or estrangement from others; and persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).

Another characteristic of PTSD is marked alterations in arousal and reactivity, including irritable behavior and angry outbursts (with little or no provocation) typically expressed
as verbal or physical aggression toward people or objects, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration,
and sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). The disturbance lasts more than one month and causes clinically significant impairment in
social, occupational, or other important areas of functioning.

Research suggests that people with Autism Spectrum Disorder (ASD) may be particularly vulnerable to PTSD. Recent research suggests that rates of PTSD in ASD are
significantly higher compared to individuals without ASD/DD. Furthermore, a PTSD diagnosis for a person with ASD may be associated with an increased likelihood of
suicidal thoughts compared to people without ASD. It has been theorized that some features of ASD, including executive functioning deficits, general processing deficits,
emotional insight deficits, and cognitive flexibility deficits, may affect traumatic
processing and memories of the traumatic event, thereby increasing the risk for PTSD.
Individuals who have both PTSD and ASD may experience a broader or different range of life experiences that can be interpreted as traumatic. These include parental divorce/separation, bullying/peer victimization, abandonment by a significant other, and trauma related to other mental health problems.

Treatment for PTSD often includes Cognitive-Behavior Therapy (CBT), which has 3 core principles: (1) Psychological problems are based, in part, on faulty or unhelpful ways of
thinking; (2) Psychological problems are based, in part, on learned patterns of unhelpful behavior; and (3) People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives. This includes addressing the emotions related to the problems. CBT may include psychoeducation about reactions to traumatic events, managing arousal, processing trauma-related emotions and trauma-related thoughts, reestablishing adaptive functioning (work and social relationships), relaxation training/stress management, thought stopping, and exposure therapy. Exposure therapy is generally considered to be the most effective intervention for PTSD. It typically incorporates at least one strategy that the individual has been previously taught to use as a means of promoting relaxation. Exposure is typically done in-vivo or
through imaginal exposure, whereby the individual is exposed to their memories of the traumatic event. The individual is then assisted in accessing the emotions associated with the trauma and he or she is taught to process the emotions, leading to memories of the event becoming less painful. This strategy is based on the premise that avoidance of the traumatic event does not allow for emotional processing. Initially, the individual works with the therapist to come up with a “trauma hierarchy,” which involves breaking down the traumatic event in terms of the least anxiety inducing part of the traumatic event, building up to the most anxiety inducing part of the traumatic event.
The therapist guides the individual through each step in the hierarchy. If anxiety occurs at any step, the individual is prompted to engage in the relaxation strategy until anxiety
is reduced. Then the anxiety-causing step is typically re-presented. When the individual experiences little or no anxiety at any step, the next step in the hierarchy is presented. This procedure is repeated until all steps in the hierarchy can be managed with little or no anxiety.

Thought Stopping is another Cognitive-Behavioral strategy that involves working with the individual to identify commonly occurring negative thoughts associated with the traumatic event and then identifying replacement thoughts. It often involves creating a signal that the individual can recall when a negative thought occurs. This signal cues the individual to stop the negative thought and instead think about the replacement thought. Examples of signals could be visualizing a “Stop” sign, visualizing railroad track crossing gates coming down, or visualizing a calming scene such as the beach or a forest. Other CBT techniques for dealing with emotional flashbacks include teaching the individual to identify triggers by writing down antecedents to a flashback; then teaching the individual to utilize coping self-statements (e.g., “I feel afraid but I’m not in danger,” “I know my flashback can be intense, but it cannot hurt me,” “My family and friends can support me during a flashback”). Writing down coping statements on a “coping card” can serve as a visual reminder of healthy statements to think about.

To manage arousal, relaxation techniques, such as breath retraining, mindfulness, and progressive muscle relaxation can be incorporated to address overarousal, especially
during emotional flashbacks and exposure training. Person centered planning can also be incorporated to assist the person in finding a path forward to a positive future.

Reference: Rumball, F., Happe, F., & Grey, N. (2020). Experience of trauma and PTSD symptoms in autistic adults: ​risk of PTSD development following DSM-5 and Non-DSM-5 traumatic life events. Autism Research, 13, 2122-2132.