Post Traumatic Stress Disorder (PTSD) #40

Post Traumatic Stress Disorder (PTSD) is a trauma- and stressor- related disorder that can develop after experiencing or witnessing a traumatic event, or learning that a traumatic event has happened to a loved one.

DSM-5 defines a traumatic event as exposure to actual or threatened death, serious injury, or sexual violence. Examples may include:

• Being involved in, or witnessing, a car accident
• Undergoing major surgery (bone marrow transplant, extensive hospitalization, or severe burns)
• Experiencing or witnessing natural disasters (earthquakes, hurricanes, floods, or fire)
• Violent crimes (kidnapping, physical assault, or assault or murder of a parent or loved one)
• Community violence (attacks at school, or suicide of a friend, family member, or a child in the same-age group)
• Chronic physical or sexual abuse
• Repeated or extreme exposure to aversive details of traumatic events (PTSD does not appear to develop from watching scary movies or playing violent video games)
• Learning that traumatic event(s) occurred to a parent or caregiving figure

Following the event, youth with PTSD report intrusive symptoms such as repetitive and upsetting memories that can present verbally such as, “I can’t stop hearing that crunch noise when the car hit the tree,” or acted out in play such as a child repeatedly hitting a toy car against the wall. Other intrusive symptoms include distressing and vivid night and day dreams (also called flashbacks whereby the child acts as if the events is actually happening in real time), and becoming highly distressed when exposed to reminders of the event. Youth can also avoid or try to stay away from any reminders of the event, report inability to recall significant details of the event, experience a range of negative emotions such as sadness, guilt, shame, and confusion, and lack interest or desire to participate in important activities. Finally, children and teens with PTSD also experience irritability, being jumpy or on edge, trouble concentrating, and sleep difficulties.  These combined symptoms must persist for more than a month following the event to meet the criteria for PTSD, although some children and teens may experience a delayed expression to the trauma so that clear signs are not noticeable until six months or more after the event.

Facts

• Approximately 4% of youth aged 13-18 will develop PTSD in adolescence
• Girls are more likely than boys to develop PTSD, and to experience symptoms for a longer duration
• The chance of developing PTSD increases with the severity of the trauma. For example, almost all children who are sexually abused or who witness the death or assault of a parent will later suffer PTSD
• Youth with PTSD may experience other problems as well, including depression, other anxiety problems, or acting-out behaviors. In teens with PTSD, substance abuse problems are also common (for example, drug or alcohol use)
• The negative effects of PTSD are far reaching impacting quality of social, occupational, interpersonal, developmental, educational, and health functioning throughout the lifespan. PTSD is also associated with increased suicide risk, suicidal ideation, and suicide attempts. Timely and effective intervention is critical.

Signs & Symptoms

Thoughts (Note that very young children they may be unable to identify specific fearful thoughts):

• It’s my fault it happened
• All men are dangerous
• I need to stay alert at all times to protect myself
• I deserved it, I’m a bad kid
• I’m a coward
• I’m not likeable and will never fit in

Physical sensations:

• Stomachache
• Headache
• Muscle tension
• Irritability
• Feeling amped up
• Feeling detached from one’s body (derealization)

Emotions:

• Sadness
• Anger
• Shame
• Guilt
• Anxiety/fear
• Confusion
• Persistent reduction in expression of positive emotions

Behaviors:

• Avoiding participating in new activities or going places
• Avoiding people, conversations, or interpersonal situations that are reminders of the traumatic event(s)
• Refusal to sleep alone or trouble falling/staying asleep
• Hypervigilance and/or exaggerated startle response
• Asking a parent to be present or available
• Recreating the traumatic event through play
• Preoccupation with reminders of the trauma
• Crying or tantrums
• Restricted play
• Trouble concentrating
• Aggression and hostility
• Avoidance of developmental opportunities in adolescence (e.g., driving, dating)

Common Situations or Affected Areas

• Avoiding contact with, or reminders of, the traumatic event
• Declining grades or academic failure
• Engaging in high risk, reckless, or dangerous behaviours
• Trouble making friends, dating, and development of meaningful relationships
• Restricting life plans or reduced ambition
• Social withdrawal

How PTSD impacts the child at different ages

Children younger than age six may not have many symptoms of PTSD. Instead, they may show their anxiety in the following ways:

• Fear of strangers.
• Fear of family members.
• General avoidance of situations that are not related to the trauma (for example, avoiding going to school, going out in public).
• Traumatic play; re-enacting parts of the trauma in their play (drawings, acting out).
• Regressive behavior (thumb sucking, bed-wetting).

Older, elementary-school-aged children with PTSD may not have symptoms of amnesia or forgetting; however, they might have some of the following symptoms:

• Omen formation. This is the belief that there were “warning signs” before the trauma occurred. Children with this belief are always on the alert for signs or warnings of “future danger”. For example, if it was raining on the day of a car accident, your child might believe that the rain was a “warning” of something bad happening, and refuse to leave the house when it rains.
• Traumatic play. Similar to very young children, elementary school children may compulsively repeat the trauma in their play. For example, a child who was traumatized by a car accident may then play with toy cars, and have them crash in to each other.

Adolescents with PTSD may experience many of the same symptoms as adults; however, there are a few key differences. For example, parents may notice dramatic changes in their teen, such as a teen who was once a straight “A” student is suddenly failing, or a teen who never used drugs and respected her curfew, is now dressing inappropriately, smoking, and staying out late. In addition, teens with PTSD often show increased aggressive and impulsive behaviours, and are at greater risk of engaging in high risk or reckless behaviors such as drug and alcohol use, speeding, unprotected sex, etc.

Lucie’s Story

Lucie is a five-year-old girl who has been living with her grandmother for almost a year since she and her parents were involved in a high impact collision resulting in their death. Lucie appears to have coped with this enormous life-changing event with surprising strength.

Although she cried a lot in the first few weeks after the accident and spoke about wanting to “go back” to be with her parents, she has been able to return to preschool three days a week and is “being a good girl” for her grandmother. However, her grandmother suspects Lucie is being “too good” and that something is not quite right. For example, Lucie’s grandmother often catches Lucie playing with her two dolls over and over again for hours at a time, almost as if she is in a daze, with no change in activity. When she tries to join in with Lucie, Lucie often walks away, refusing to talk. At other times when her grandmother pushes her to try something new or fun, Lucie will erupt into a massive tantrum that seems unreasonable given the situation. Finally, Lucie often seems tired and unrested; as if she is not getting enough sleep despite the fact she is in bed for eleven hours nightly. Lucie’s grandmother is starting to suspect Lucie is having a delayed reaction to the loss of her parents and worries that Lucie has lost her spark.

Ms. Chan’s Story

Ms. Chan is a 25-year-old paralegal who shares a small apartment with her 16-year-old sister. It has been a month since Ms. Chan and her sister moved out of their parents’ home after years of witnessing their father abuse their mother both verbally and physically.

Ms. Chan always tried to protect her little sister from what was happening; however, recent changes in her sister’s behavior have got her worried. For example, Ms. Chan has noticed her sister always seems to be on edge, jumping at the slightest noise. In addition, she hardly sleeps, is irritable and withdrawn, and appears to have lost weight. The most recent indication that her sister is suffering has been her decision to delay going to college, opting to work full time at the local grocery store instead. Ms. Chan is worried her sister may be suffering some sort of stress reaction from witnessing so much violence at home.

Eric’s Story (PTSD)

Eric is a 13-year-old boy who was always very outgoing and had lots of friends in school. About a year ago, he dropped out of soccer and karate lessons, even though he used to love both activities. He started staying at home after school instead of seeing his friends, and arguing with his mom about going to school.

Eric also started calling his mom many times on her cell phone whenever she left the house. Eric’s problems started after a trauma he experienced about a year ago. While driving to the mall with his mom, a car ran a red light and hit the side of their car. Eric’s mom’s car spun several times and hit a tree. The driver of the other car suffered a serious head wound. Luckily, neither Eric nor his mom were hurt. Eric said that he could still remember what the man in the other car looked like with blood trickling down from his forehead to his face, “like a color picture in my head”.

After the accident, Eric was terrified of being in cars. He was even afraid of walking down the street, saying that there are “crazy drivers everywhere”, and he was worried that he would get hit by a car. When he does leave the house, he insists that his mom come with him, and he becomes very anxious when she is out of his line of sight. Eric also has nightmares about car crashes, and he says he keeps having thoughts pop into his head about the accident. He gets very anxious when he hears a car horn honking, or if he sees a news article about car accidents. He no longer watches the news or TV shows that contain any violence.

Aman’s Story