Evidence-Based Interventions
Following Exposure to Trauma
Teresa L. Kramer, Ph.D., Professor and Chief Psychologist
Psychiatric Research Institute
University of Arkansas for Medical Sciences
Objectives
• Highlight recent research documenting the longterm, multi-generational, multi-systemic impact
of trauma
• Compare diagnostic formulations of posttraumatic stress disorder from DSM-IV to DSM-V
• Describe recent psychotherapeutic and
pharmacological developments in the treatment
of PTSD
Objectives
• Highlight recent research documenting the longterm, multi-generational, multi-systemic impact
of trauma
PTSD – From Trauma to
Maladaptive Coping
Brains Have the Ability to Adapt to
Environment
• Allostasis: Physiological adjustment to environmental
pressures Ganzel et al 2010
• Allows organism to adapt to circumstances
• Increased arousal is adaptive when running from a
bear or when experiencing a trauma
• Allostatic load: cumulative consequences of allostasis:
• Physiological state is (semi-) permanently changed
• Adaptive if I live in a place with lots of bears or if
I’m chronically abused as a child
Gets stronger in chronically stressful
environments
Gets weaker in chronically stressful
environments
Amygdala – allows us to detect
objects/situations that are
biologically relevant
Medial Prefrontal Cortex –
allows us to control our
emotions when needed
A Metaphor for Structural Brain
Consequences of Chronic Stress
Amygdala +
OFC Density
=
Speed of
River Current
Hippocampus+ PFC
Density
=
Strength of Dam
With chronic stress, river current gets faster and faster, while
strength of dam gets weaker and weaker.
Adverse Childhood
Experiences (ACE)
• One of the largest investigations ever conducted to assess
associations between childhood maltreatment and later-life
health and well-being.
• Collaboration between the Centers for Disease Control and
Prevention and Kaiser Permanente's Health Appraisal Clinic in
San Diego.
• 17,000 Health Maintenance Organization (HMO) members
• Comprehensive physical examination
• Detailed information about childhood experience of abuse,
neglect, and family dysfunction
• More than 50 scientific articles published
Risk Factors Related to ACE
As the number of ACE increase, the risk for the following health problems increases in a strong
and graded fashion:
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Alcoholism and alcohol abuse
Chronic obstructive pulmonary disease (COPD)
Depression
Fetal death
Health-related quality of life
Illicit drug use
Ischemic heart disease (IHD)
Liver disease
Risk for intimate partner violence
Multiple sexual partners
Sexually transmitted diseases (STDs)
Smoking
Suicide attempts
Unintended pregnancies
Early initiation of smoking
Early initiation of sexual activity
Adolescent pregnancy
Fetal Origins of Adult Disease
(genetics)
Impact of Glucocorticoids
(environment)
Impact of Exposures
Maternal Abuse History and Infant
Baseline Salivary Cortisol
Baby Baseline Cortisol
0.6
0.5
0.4
0.3
No Abuse History
Abuse History
0.2
0.1
N = 78
0
N = 26
Maternal Abuse History, PTSD and
Infant Cortisol Reactivity
Log AUC Relative to Baseline
2.45
2.4
2.35
No Abuse History
2.3
Abuse History
2.25
2.2
2.15
All
No PTSD
Subjects
(Brand et al PNEC 2008)
PTSD
45.5%
p=.016
Percent of Subjects Requiring
Emergency C-Section
50%
45%
Impact of Severe Early
Abuse on Outcome
40%
35%
30%
14.3%
25%
20%
15%
10%
5%
0%
Not Exposed to 2 or More Types of
Severe Abuse
Exposed to 2 or More Types of
Severe Abuse
Maternal History of Severe Childhood Abuse Predicts
Increased Risk of Neonatal Respiratory Distress Syndrome
p=.017
40.0%
Percent of Subjects whose Neonates
had Respiratory Distress Syndrome
50%
45%
40%
35%
30%
25%
• Control for diagnoses, symptoms in
pregnancy, other exposures, AD, etc.
• Women with history of severe abuse
(sexual, physical, emotional), had
higher rates:
• Emergency C/S
• Hypertension in pregnancy
• Low birth weight (<2500 gm)
• Neonatal respiratory distress
• Maternal Urine Cotinine associated
with LBW, Neonatal Symptoms
20%
15%
3.6%
(Weiss et al Thesis MCR Program)
10%
5%
0%
Not Exposed to 2 or More Types
of Severe Abuse
Exposed to 2 or More Types of
Severe Abuse
Maternal Report – CBCL and Early Abuse
• Affective Problems
• (t=3.64; p=0.0004)
Offspring Affective Problem Score
3.0
2.5
2.0
1.5
1.0
0.5
0.0
No
Yes
Maternal Sexual Abuse
• Anxiety
• (t=4.25; p<0.0001)
Offspring Anxiety Score
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
No
• Oppositional Defiant
Smith A. et al SOBP 2009
Offspring Oppositional Definant Score
• (t=1.98; p=0.049)
Yes
Maternal Sexual Abuse
3.5
3
2.5
2
1.5
1
0.5
0
No
Yes
Maternal Sexual Abuse
Summary
• Maternal – Early Adverse Life Events
• Higher rates of the following:
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C-Section
Hypertension in pregnancy
Low birth weight
Neonatal respiratory distress
• Decreased cord (fetal) HPA response to delivery
• Lower baseline infant cortisol at 6 months
• Higher infant cortisol reactivity at 6 months
• Later Infant/Child Follow Up
• Depression and early abuse associated with
adverse effects
Multi-Generational Impact
The cumulative burden borne by offspring whose mothers were sexually abused as children:
descriptive results from a multigenerational study.
Abstract
This multigenerational study empirically demonstrates the extent to which offspring whose
parents experienced childhood abuse are at increased risk of being abused or neglected.
Females with substantiated childhood sexual abuse and non abused comparison females were
assessed at six points spanning 18 years in a prospective, longitudinal study. Non abusing
parents or caregivers and offspring were also assessed. Descriptive results indicate that
offspring born to mothers with histories of sexual abuse were more likely to be born preterm,
have a teenage mother, and be involved in protective services. Abused mothers were more
likely to be high-school dropouts, be obese, and have experienced psychiatric problems,
substance dependence, and domestic violence. Results provide evidence for the advantages of
intervention and prevention programs for victims of childhood maltreatment and their
families. Primary prevention/intervention efforts extending throughout development and
focusing on the cumulative risk to offspring will likely improve victim outcomes and curtail
intergenerational transmission of adversity
(Noll JG, Trickett PK, Harris,WW, Putnam FW, 2009)
Objectives
• Compare diagnostic formulations of posttraumatic stress disorder from DSM-IV to DSM-V
DSM Overview
• No longer categorized as an anxiety disorder; currently
identified as “Trauma- and Stressor-Related Disorder”
• Category also includes Reactive Attachment Disorder and
Disinhibited Social Engagement Disorder
• Separate diagnosis for children six years and younger
(Posttraumatic Stress Disorder for Children Six Years and
Younger)
• Includes “secondary victimization,” (e.g., police officers
repeatedly exposed to details of child abuse)
• Does not require that the initial response involved “intense
fear, helplessness or horror” (second part of Criterion A that
has been controversial)
• Symptoms described as “beginning after the “traumatic event
occurred”
DSM Changes
• DSM-IV-TR
• Intrusive Symptoms (1
or more)
• Distressing
recollections
• Distressing dreams
• Acting/feeling as if the
event were recurring
• Intensive psychological
distress at reminders
• Physiological reactivity
to reminders
• DSM-V
• Intrusive Symptoms (1
or more)
• Distressing memories
• Distressing dreams
• Dissociative reactions
• Intense psychological
distress at reminders
• Marked physiological
reactions to reminders
DSM Changes (continued)
• DSM-IV-TR
• Avoidance (3 or more)
• Avoidance of
thoughts/feelings
related to trauma
• Avoidance of activities,
places related to trauma
• Can’t recall memories of
trauma
• Diminished interest
• Detachment
• Restricted affect
• Sense of foreshortened
future
• DSM-V
• Avoidance (1 or more)
• Avoidance of distressing
memories, thoughts,
feelings related to
trauma
• Avoidance of external
reminders related to
trauma
DSM Changes (Continued)
• DSM-IV-TR
• Included under avoidance
• Included under avoidance
• Included under avoidance
• Included under avoidance
• DSM-V
• Negative alterations in
cognitions and moods related
to trauma (2 or more)
• Can’t recall memories of
trauma
• Negative beliefs about
oneself
• Persistent/distorted
cognitions about trauma
• Persistent negative
emotional state
• Diminished interest
• Detachment/estrangement
• Inability to experience
positive emotions
DSM Changes (continued)
• DSM-IV-TR
• Hyperarousal (2 or
more)
• Difficulty with sleep
• Irritability or anger
• Concentration
problems
• Hypervigilance
• Exaggerated startle
• DSM-V
• Hyperarousal (2 or
more)
• Difficulty with sleep
• Irritability or anger
• Concentration
problems
• Hypervigilance
• Exaggerated startle
• Reckless or selfdestructive behavior
Objectives
• Describe recent psychotherapeutic and
pharmacological developments in the treatment
of PTSD
Psychological Treatments
• Adults
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Cognitive-Exposure Therapy (3 studies)
Cognitive Processing Therapy (4 studies)
EMDR (3 studies)
Cognitive Therapy (3 studies)
CBT Mixed (6 studies)
• Children & Adolescents
• Prolonged Exposure Therapy (1 study; adolescents only)
• Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) (5 studies;
C&A)
• Risk Reduction through Family Therapy (1 study; adolescents only)
• EMDR (3 studies; C&A)
• Cognitive Processing Therapy (1 study; adolescents only)
• Parent Child Interaction Therapy (3-7 years)
• Child Parent Psychotherapy (1 study; <6 years)
• Cognitive-Behavioral Therapy – Various Forms (7 studies; C&A)
Pharmacological Treatments
• SSRI
• Fluoxetine
• Paroxetine
• Sertraline
• SNRI
• Venlafaxine
• Anti-Convulsant
• Topiramate
• Evidence insufficient for all other medications
Jonas, DE, Cusack, K, Forneris, CA, Wilkins, TM, Sonis, J, Middleton JC, Feltner, C, Meredith, D, Cavanaugh, J, Brownley,
KA, Olmsted, KR, Greenblatt, A, Weil, A, Gaynes, BN. (2013). Psychological and pharmacological treatments for adults
with posttraumatic stress disorder (PTSD). Comparative Effective Reviews, No. 92, RTI International–University of
North Carolina Evidence-based Practice Center Rockville (MD): Agency for Healthcare Research and Quality , Report
No.: 13-EHC011-EF; https://www.ncbi.nlm.nih.gov/books/NBK137707/
Leenarts, L.EW, Diehle, J, Doreleijers, TAH, Jansma, EP, Lindauer, RJL. (2013). Evidence-based treatments for children
with trauma-related psychopathology as a result of childhood maltreatment: a systematic review. European Child &
Adolescent Psychiatry, 22: 269-283.
Complex PTSD
• Phased-Oriented or Sequential Treatment
1.
Stabilization and skills strengthening
• Patient safety
• Strengthening individual’s capacities for emotional
awareness/expression, interpersonal and social competencies
2.
3.
Review and reappraisal of trauma memories
Consolidation of gains
• Application of skills
• Future plans
• Use of “booster” sessions
PRI Research with Adolescent Girls
• NIMH-funded study to identify brain correlates of psychological treatment
outcome for adolescent girls with PTSD
• 12 sessions of TF-CBT free of charge
• Conduct a clinical interview and brain scan before and after treatment
• Monetary compensation for time
• Child gets ~$225; parent gets $75
• Monetary compensation for travel to each visit to UAMS (~15 vists * $15 per
visit)
• Inclusion criteria:
• Female, aged 11-16, PTSD related to physical or sexual assault
• Contact:
• Sonet Smitherman: 526-8386; smsmitherman@uams.edu
• Josh Cisler: 526-8343; jcisler@uams.edu
Programmatic Initiatives
Arkansas Building
Effective Services for
Trauma
The mission of AR BEST is
to improve outcomes for
traumatized children and
their families in Arkansas
through excellence in clinical
care, training, advocacy and
research/evaluation.
Programmatic Initiatives
• Arkansas Network for Early Stress and Trauma
(Arkansas NEST)
• Collaboration between PRI, Mid-South Health Systems, and Ozark
Guidance Center and funded by the Substance Abuse and Mental
Health Services Administration Member of the National Child
Traumatic Stress Network (NCTSN)
• To increase services in Arkansas for children aged 0-5 years who
have experienced trauma
Acknowledgements
• Zachary Stowe, M.D., Director of PRI’s Women’s Mental Health
Program
• Josh Cisler, Ph.D., PRI Assistant Professor