Mental Health Disorders in Children
Subtopic:
Post-traumatic stress disorder (PTSD)
Post-traumatic stress disorder (PTSD) is classified as an anxiety disorder distinguished by a cluster of symptoms including hyperarousal, re-experiencing traumatic memories, and avoidance of trauma reminders.
PTSD is a condition that develops after an individual witnesses, is directly involved in, or learns about (experiences) an exceptionally traumatic stressor.
It is a condition that arises when a person experiences an extremely rare and stressful event and reacts with intense anxiety, emotional numbing, and avoidance of thoughts related to the event. This avoidance is frequently punctuated by sudden, vivid, and distressing recollections of the traumatic experience.
PTSD is recognized as a mental health disorder frequently associated with torture and severe trauma.
PTSD can manifest as an immediate response to the stressor or may emerge after a delay of days or even months. While PTSD symptoms typically improve within months, in some cases, the condition can become chronic and persist for years.
Post-Traumatic Stress Disorder was formally recognized as a distinct psychiatric disorder in 1980 by the American Psychiatric Association (APA). Historically, PTSD has been referred to by various terms, including:
Shell shock (used in wartime contexts)
Soldiers’ heart (historical term for combat-related stress)
Rape trauma syndrome (specific to sexual assault survivors)
Concentration camp syndrome (observed in Holocaust survivors)
Etiology (Causes of PTSD)
Exceptional Stressful Event: The primary etiological factor is exposure to an exceptionally stressful event where the individual is either directly involved or witnesses the event.
Examples of Traumatic Events:
War and combat situations
Natural disasters (floods, earthquakes)
Gang rape and sexual assault
Acts of terrorism
Serious accidents (e.g., motor vehicle accidents)
Fires and explosions
Individual Vulnerability: Responses to trauma vary significantly among individuals, indicating the role of personal vulnerability factors.
Genetic Predisposition: Twin studies have provided evidence suggesting a genetic component to vulnerability to PTSD.
Predisposing Factors: Several factors can increase an individual’s susceptibility to developing PTSD:
Uncontrolled Temperament: Individuals with pre-existing difficulties in emotional regulation and impulse control may be more vulnerable.
Age: Children and older adults are often identified as being more susceptible to the psychological impact of trauma.
Gender: Women have been found to have a higher prevalence of PTSD compared to men in some studies.
History of Psychiatric Disorders: Individuals with a pre-existing history of mental health disorders are at increased risk.
Previous Traumatic Experiences: A history of prior traumatic experiences, including childhood adversity like separation from parents or child abuse, can elevate vulnerability.
Cognitive Appraisal Differences: Variations in how individuals interpret and process threatening events and how these events are encoded in memory in the brain can influence PTSD risk.
Neuroendocrine Factors: Neurobiological changes in the stress response system play a significant role:
Sensitization of the Noradrenergic System: Increased sensitivity and reactivity of the noradrenergic neurotransmitter system, involved in the stress response and arousal.
Sensitization of the Serotonergic System: Alterations in the serotonergic system, which regulates mood, anxiety, and sleep.
Reduction in Cortisol Levels: Lower than normal levels of cortisol, a stress hormone, in some individuals with PTSD, potentially indicating dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis.
Psychological Theories: Various psychological theories attempt to explain the development of PTSD:
Fear Conditioning: Classical conditioning mechanisms may be involved, where traumatic events become associated with fear responses to previously neutral stimuli.
Cognitive Theory: PTSD is proposed to arise when the normal cognitive processing of emotionally charged information is overwhelmed. This results in traumatic memories being stored in an unprocessed form, leading to intrusive and distressing recollections that intrude into conscious awareness.
Psychodynamic Theory: This perspective emphasizes the role of past experiences and unresolved psychological conflicts in shaping an individual’s response to severely stressful events and their vulnerability to PTSD.
Maintaining Factors: Factors that can perpetuate PTSD symptoms and hinder recovery include:
Negative Appraisal of Early Symptoms: Catastrophic interpretation of initial PTSD symptoms, leading to increased anxiety and symptom amplification.
Avoidance of Reminders: Avoidance of trauma-related cues and reminders prevents both deconditioning of fear responses and cognitive reappraisal of the traumatic experience, thus maintaining symptom intensity.
Suppression of Anxious Thoughts: Active attempts to suppress or inhibit anxious thoughts related to the trauma can paradoxically increase their frequency and intensity over time.
Diagnostic Criteria: Signs and Symptoms of PTSD
The diagnostic criteria for PTSD, as outlined in diagnostic manuals, typically include the following symptom clusters:
Exposure to Traumatic Event: The individual must have been exposed to a traumatic event that is outside the range of usual human experience and would be profoundly distressing to almost anyone. This exposure can occur through:
Directly experiencing the trauma.
Witnessing the trauma occurring to others.
Learning that the trauma occurred to a close family member or friend (actual or threatened death, serious injury, sexual violence).
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).
Persistent Re-experiencing of the Traumatic Event: Characterized by intrusive and distressing recollections:
Recurrent and Intrusive Recollections: Intrusive memories, thoughts, or images of the traumatic event that repeatedly come to mind.
(In young children, this may manifest as repetitive play where themes or aspects of the trauma are expressed).
Recurrent Distressing Dreams: Nightmares or disturbing dreams where the content is related to the traumatic event.
(In children, there may be frightening dreams without recognizable content).
Acting or Feeling as if the Traumatic Event Were Recurring: Flashbacks or dissociative episodes where the individual feels or acts as if the traumatic event is happening again in the present.
(In children, trauma-specific re-enactment may occur in play).
Intense Psychological Distress at Trauma Reminders: Experiencing intense psychological distress when exposed to cues or stimuli (internal or external) that symbolize or resemble an aspect of the traumatic event.
Physiological Reactivity to Trauma Reminders: Marked physiological reactions (e.g., increased heart rate, sweating, startle response) upon exposure to events that symbolize or resemble the traumatic event.
Persistent Avoidance of Stimuli Associated with the Trauma: Efforts to avoid trauma-related thoughts, feelings, and reminders:
Efforts to Avoid Thoughts or Feelings: Deliberate attempts to avoid trauma-related thoughts, memories, feelings, or sensations.
Avoidance of External Reminders: Avoiding external reminders (people, places, conversations, activities, objects, situations) that arouse recollections of the trauma.
Inability to Recall Trauma Aspects: Inability to recall important aspects of the trauma (dissociative amnesia), not due to head injury, alcohol, or drugs.
Diminished Interest in Activities: Markedly diminished interest or participation in significant activities that were previously enjoyed.
Feeling of Detachment from Others: Feelings of detachment or estrangement from others, emotional distance.
Restricted Range of Affect: Restricted range of affect (emotional numbing), inability to experience positive emotions like happiness, love, or satisfaction.
Sense of Foreshortened Future: Sense of a foreshortened future, expectation that one’s life will be significantly limited, or not expecting to have a normal life span, career, marriage, children, etc.
Persistent Symptoms of Increased Arousal (Hyperarousal): Reflecting heightened reactivity and vigilance:
Difficulty Falling or Staying Asleep: Sleep disturbance, insomnia, difficulty initiating or maintaining sleep.
Irritability or Outbursts of Anger: Increased irritability or proneness to anger, potentially manifesting as angry outbursts or aggression.
Difficulty Concentrating: Impaired concentration and attention.
Hypervigilance: Hypervigilance: An exaggerated state of watchfulness and scanning the environment for threats, feeling constantly “on guard.”
Exaggerated Startle Response: Exaggerated startle response: Being easily and excessively startled by unexpected noises or movements.
Duration of Symptoms: Symptom persistence is a key diagnostic criterion:
Symptoms for at Least One Month: The disturbance (symptoms in Criteria B, C, and D) must last for more than one month to meet PTSD diagnostic criteria.
Categorization by Duration:
Acute PTSD: If symptoms last for less than 3 months.
Chronic PTSD: If symptoms persist for more than 3 months.
Delayed-Onset PTSD: If symptom onset occurs at least 6 months after the traumatic stressor.
Summary of Core Symptoms of PTSD
The primary symptom clusters in Post-Traumatic Stress Disorder can be summarized as:
Hyperarousal:
Persistent anxiety, heightened alertness.
Irritability and increased reactivity.
Insomnia and sleep disturbances.
Poor concentration and attention deficits.
Intrusions (Re-experiencing):
Difficulty in voluntarily recalling details of the stressful event.
Intense intrusive imagery and sensory recollections (flashbacks).
Recurrent distressing dreams and nightmares related to the trauma.
Avoidance:
Active avoidance of reminders of the traumatic events, both internal (thoughts, feelings) and external (places, people, situations).
Emotional detachment from others and social withdrawal.
Emotional numbing and inability to feel positive emotions (anhedonia).
Diminished interest or participation in previously enjoyed activities.
Reactions: Common emotional and behavioral reactions associated with PTSD:
Nightmares and terrifying dreams.
Vivid and intrusive recall of traumatic events (images, sensations).
Persistent depression or sadness.
Increased irritability and anger.
Elevated anxiety levels, even in non-threatening situations.
Development of anti-social behaviors in some cases as a coping mechanism or consequence of trauma.
Management of PTSD
Treatment for PTSD typically involves a multimodal approach, often combining psychotherapy, counseling, and medication.
Assessment
A comprehensive assessment is essential to guide treatment planning. Key areas of assessment include:
Nature and Severity of Stressful Event: Detailed history of the traumatic event(s), including type, duration, and intensity of exposure.
Nature and Duration of Symptoms: Thorough evaluation of PTSD symptoms, including onset, duration, frequency, intensity, and impact on functioning.
Previous Psychiatric History: Assessment of any pre-existing mental health conditions or history of psychiatric treatment.
Pre-Trauma Personality: Understanding the individual’s personality traits and coping styles prior to the traumatic event.
Neurological Examination: A neurological examination should be performed, especially if the traumatic event involved physical injury, such as in cases of assault or accidents. This helps to:
Exclude Subdural Hematoma: Rule out subdural hematoma or other forms of cerebral injury that may present with psychiatric symptoms.
Treatment Strategies
Early Intervention and Treatment:
Mild Response Support: If the initial response to trauma is not severe, sympathetic support and practical assistance in addressing immediate problems arising from the disaster or traumatic event may be sufficient.
Counseling: Counseling is crucial in the early phase, providing:
Emotional Support: Validation, empathy, and a safe space to process emotions.
Discouraging Recall: In the immediate aftermath, avoid pressuring the individual to repeatedly recount traumatic details, as this can be retraumatizing.
Facilitating Emotional Processing: Help individuals gradually work through associated emotions like fear, grief, and anger.
Anxiolytic Medication (Short-Term): A few doses of anxiolytic drugs (anti-anxiety medications) may be used judiciously and short-term to help calm the person and manage acute anxiety symptoms, but long-term use is generally avoided due to dependence risks.
Event Reconsideration and Feeling Expression: Guide the person to talk about and reconsider the traumatic event in a safe and supportive environment, encouraging them to express their feelings related to the trauma. This process may need to be repeated over multiple sessions.
Treatment of Chronic PTSD: Chronic PTSD is often more complex and challenging to treat, requiring more intensive and specialized interventions.
Trauma-Focused Psychotherapy: Psychotherapy is the cornerstone of chronic PTSD treatment.
Prolonged Exposure Therapy: Requires a series of therapy sessions where the individual is:
Encouraged to recall the traumatic event in detail.
Re-experience the emotions associated with the trauma in a controlled therapeutic setting.
Work through unprocessed emotions and memories.
Cognitive Therapy Techniques: Cognitive therapy techniques are used to help patients:
Desensitize Patients to Reminders: Reduce emotional reactivity to trauma-related cues and reminders.
Challenge and Reframe Negative Thoughts: Identify and modify maladaptive or negative thought patterns related to the trauma and its aftermath.
Process Traumatic Images: Help patients process and integrate intrusive traumatic images and memories in a more adaptive way.
Tailored Psychotherapy Options: Psychotherapy approaches are specially tailored to address trauma, focusing on trauma processing, emotional regulation, and cognitive restructuring.
Cognitive Processing Therapy (CPT): A specific type of cognitive therapy for PTSD, also known as cognitive restructuring.
Cognitive Restructuring: Patients are taught to re-evaluate and modify their thoughts about the traumatic event and its impact.
Mental Imagery: Utilizing mental imagery of the traumatic event in therapy sessions can help patients:
Work through the trauma in a safe environment.
Gain a sense of control over their fear and distress associated with the traumatic memories.
Exposure Therapy: A behavioral therapy technique effective for reducing avoidance and fear responses.
Repeatedly Talking About the Event: Patients talk about the traumatic event in detail with the therapist in a safe and controlled setting.
Confronting Fear Cues: Involves gradually confronting situations, places, or cues that trigger fear and anxiety related to the trauma.
Controlled Environment: Exposure is conducted in a safe and controlled therapeutic environment to minimize distress and promote a sense of security.
Increased Control: Exposure therapy helps the person feel they have more control over their thoughts and feelings associated with the trauma over time.
Medications: Medications can be used to manage specific PTSD symptoms, often in conjunction with psychotherapy.
Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs, such as paroxetine (Paxil) and sertraline (Zoloft), are commonly used first-line medications for PTSD.
Multifaceted Symptom Relief: SSRIs help treat core PTSD symptoms, as well as common co-occurring conditions such as depression, anxiety, and sleep problems.
Benzodiazepines: Benzodiazepines may be considered for short-term management of severe irritability, insomnia, and anxiety associated with PTSD. However, their use is generally limited and cautious due to concerns about dependence and lack of effectiveness in treating core PTSD symptoms.
National Center for PTSD Recommendation: The National Center for PTSD generally does not recommend benzodiazepines for routine PTSD treatment due to:
Lack of Impact on Core Symptoms: Benzodiazepines do not effectively treat the core symptom clusters of PTSD (re-experiencing, avoidance, hyperarousal).
Dependency Risk: Potential for physiologic and psychological dependence with prolonged use.
Anxiolytics – Avoid Unless Necessary: Anxiolytics (non-benzodiazepine anxiety medications) should be avoided in long-term PTSD management unless specifically indicated and carefully monitored due to potential for dependence and limited efficacy for core PTSD symptoms.
Antidepressants (Low Doses): Antidepressants, particularly SSRIs or SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors), are more commonly used for long-term management. In some cases, low doses of other antidepressants, such as mirtazapine or trazodone, may be used, particularly for sleep disturbances or anxiety.
Self-Help Techniques for PTSD Management
Empowering patients with self-help strategies is a crucial aspect of PTSD recovery:
Active Coping: Active coping strategies are essential for recovery. Active coping:
Enables Acceptance: Helps a person accept the impact of the traumatic event on their life.
Promotes Action: Encourages taking proactive steps to improve their situation and well-being.
Education and Understanding: Learning about PTSD is empowering. Understanding:
Ongoing Response is Normal: Helps to normalize the PTSD symptom response, recognizing that it is a typical reaction to trauma.
Recovery Takes Time: Emphasize that recovery from PTSD is a process that takes time and is not a linear or immediate event.
Acceptance and Coping:
Healing vs. Forgetting: Accepting that healing does not necessarily mean forgetting the trauma, but rather learning to live with the memories in a way that is less distressing and disruptive.
Reduced Symptom Bother: Gradually feeling less bothered by PTSD symptoms over time.
Confidence in Coping: Building confidence in one’s ability to cope with bad memories and triggers when they arise.
Other Helpful Strategies: Additional self-help techniques and lifestyle adjustments that can support PTSD recovery include:
Confiding in Someone: Finding a trusted person to confide in and share experiences with can provide emotional release and support.
Social Support: Spending time with other people who understand or have shared similar experiences can reduce feelings of isolation and validate experiences.
Trigger Awareness and Communication: Letting people close to you know what might trigger symptoms can help create a supportive environment and reduce unexpected triggers.
Task Breakdown: Breaking down large tasks into smaller, more manageable parts can improve focus, reduce overwhelm, and enhance a sense of accomplishment.
Physical Exercise: Engaging in regular physical exercise, such as swimming, walking, or other activities, can improve mood, reduce stress, and promote physical health.
Relaxation Techniques: Practicing relaxation techniques, such as deep breathing exercises, progressive muscle relaxation, or meditation, can help manage anxiety and promote calmness.
Mindfulness and Nature: Listening to quiet music or spending time in nature can have a calming and grounding effect, reducing stress and promoting well-being.
Patience and Self-Compassion: Understanding that it will take time for symptoms to improve and practicing self-compassion and patience throughout the recovery journey.
PTSD is Not Weakness: Accepting that PTSD is not a sign of personal weakness or failure, but a condition that can affect anyone exposed to trauma.
Enjoyable Activities: Actively participating in enjoyable activities and hobbies that can provide distraction, pleasure, and a sense of normalcy and routine in life.