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This week’s blog was contributed by Jeremy Sharp, PhD, licensed psychologist and clinical director at the Colorado Center for Assessment & Counseling and the host of the Testing Psychologist Podcast. Dr. Sharp earned his undergraduate degree in experimental psychology from the University of South Carolina and earned his master’s degree and doctorate in counseling psychology from Colorado State University. He specializes in psychological and neuropsychological evaluation of children and adolescents and provides private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. He lives in Fort Collins, Colorado with his wife (also a therapist) and two kids.

First, what IS trauma? The DSM-5 definition is easy to find, but the very first requirement for a PTSD diagnosis (“Exposure to actual or threatened death, serious injury, or sexual violence…”) does not capture the broad range of experiences that may lead to a trauma response. Right away, we find the categorical nature of the DSM-5 may not adequately conceptualize or capture the huge continuum of traumatic experiences. I think we can all agree that not all “traumatic” experiences involve exposure to death, serious injury, or sexual violence. What about neglect? What about emotional or psychological abuse? It is necessary to further define trauma and the many ways it can occur. One way to break it down a little further is to distinguish between acute (“Big T”) trauma and developmental or complex (“little T”) trauma. 

Acute trauma refers to a discrete event that occurs at a single point in time. With acute trauma, one can generally identify a clear change in functioning from before the event to after the event. An acute trauma may be something like a sexual assault, a car accident, or being held up at gunpoint. Complex trauma is more complicated and refers to ongoing, recurrent traumatic experiences. When these recurrent traumatic experiences happen during childhood, the collective experience is called developmental trauma.


Related post: Assess the impact of the pandemic on kids—the PASS-12 is now available!

 

Why is this distinction relevant for us as clinicians? Because it affects how we assess and treat individuals. We know that individuals with acute trauma typically may have a quicker path to recovery, while individuals with complex trauma tend to show more chronic symptoms. Acute trauma is also easier to assess in the sense that we are only gathering information about one event, with a relatively clear before and after, while complex trauma tends to be multilayered.

Regarding the assessment process specifically, detailed questions about trauma should be included in nearly all diagnostic interviews. As mentioned earlier, many parents and individuals can overlook or downplay potentially traumatic experiences. Kids also may not share their traumatic experiences with their parents or others unless asked directly. There are a couple of ways to get at these concerns without coming across as too heavy-handed. One is to say something like, “Tell me about some of the most important events in your life” or “What are the top three hardest/worst things that you can remember?” or “Have you held any secrets for a long time that you’d like to share?” Note that forensic interviewing is a clear subspecialty in our field. Do NOT practice outside the scope of your expertise! Another way to explore these questions is to use a broadband questionnaire as a guide for topics/events to inquire about. If your client shares anything that warrants further exploration, you can integrate a narrower questionnaire to drill down on specific trauma symptoms.

Moving further down the path of the assessment process, it is important to think through the relationship between trauma and other mental health diagnoses. A question that comes up often is, how to separate trauma from ADHD/autism/anxiety, etc. As Dr. Maggie Sibley and Dr. Julia Strait noted on past Testing Psychologist podcast episodes, maybe we don’t. Maybe we need to stop thinking about how to separate these diagnoses, because it is nearly impossible to do so, particularly in the case of developmental trauma. Even going by the DSM-5 definition of PTSD or acute stress disorder, there are many PTSD symptoms that occur in other diagnoses. These symptoms include repetitive play (autism), intrusive memories/thoughts (OCD), distress when exposed to certain cues (specific phobia), poor memory (ADHD), and alterations in cognition (depression, anxiety, ADHD), just to name a few. Unless we have a clear picture of functioning before the trauma started, it is extremely challenging to know if these symptoms “belong” to the trauma or something else. In these (and all) cases, gathering an accurate history is crucial to establishing context to interpret an individual’s symptoms and assessment results. 

In cases when an accurate history is not available from the primary caregiver, clinicians may need to expand the scope of the evaluation and incorporate a broader record review or interviews with additional people in the client’s life. Even then, we sometimes must simply do our best with what we’ve got to come up with meaningful conceptualization and recommendations.

Ultimately, we want our assessment to guide treatment and provide helpful recommendations for our clients. By conducting a thorough clinical interview; utilizing well-standardized assessment instruments; and providing realistic, evidence-based recommendations, testing psychologists play a vital role in helping individuals identify and heal from their adverse experiences.

Catch up with the Testing Psychologist podcast on their website, via Apple Podcasts, Google Podcasts, or on Spotify.
 

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Trauma touches people at every level of our society: children who have witnessed violence; soldiers with posttraumatic stress disorder; adults who have experienced traumatic losses. PAR is proud to offer a number of assessment instruments that can assist in the evaluation and treatment of trauma across the age range.

Here are just some of the trauma-based instruments we have available:

Trauma Symptom Inventory-2 (TSI-2): The gold-standard measure to evaluate the effects of traumatic events in adults ages 18 years and older.

Trauma Symptom Checklist for Young Children (TSCYC): The first broadband trauma measure for children ages 3 to 12 years who have been exposed to traumatic events.

Trauma Symptom Checklist for Children (TSCC): Allows you to measure posttraumatic stress and related symptomatology in children ages 8 to 16 years.

Trauma Symptom Checklist for Children Screening Form (TSCC-SF) and
Trauma Symptom Checklist for Young Children Screening Form (TSCYC-SF): Allow you to quickly screen children from ages 3 to 17 years for symptoms of trauma and determine if follow-up evaluation and treatment is warranted.

Detailed Assessment of Posttraumatic Stress (DAPS): A self-report instrument for adults ages 18 and above that provides a detailed assessment of PTSD in a short amount of time.

The TSCYC, TSCC, TSCYC-SF, TSCC-SF, and TSI-2 are also available in Spanish.

Help those dealing with trauma, no matter the cause or their age. To learn more, click on any of the product name links above.
You may know the Trauma Symptom Checklist for Young Children (TSCYC) evaluates acute and chronic posttraumatic symptomatology in young children in just 15 to 20 minutes. Here are five things you may not know.

  1. The TSCYC is the first fully standardized and normed broadband trauma measure for young children ages 3-12 years who have been exposed to traumatic events such as child abuse, peer assault, and community violence.

  2. The TSCYC is customizable: The test features a caretaker report that rates symptoms observed during the previous month and includes separate profile forms for males and females in three age groups: ages 3-4 years, ages 5-9 years, and ages 10-12 years.

  3. The TSCYC is reliable and valid: It meets the new 2017 standards for use in Children’s Advocacy Centers.

  4. The TSCYC has free online training. Get up to speed quickly with a short instructional video describing the administration, scoring, and interpretation of the TSCYC—available at no charge on the PAR Training Portal.

  5. The TSCYC is convenient. Administer and score with paper and pencil or 24/7 via PARiConnect, our online assessment platform.


Learn more about the TSCYC!
You may know the Trauma Symptom Checklist for Children (TSCC) evaluates posttraumatic stress symptomatology in individuals 8 to 16 years old. Here are five things you may not know:

  1. The TSCC is comprehensive: The TSCC measures posttraumatic stress and related psychological symptomology in children and adolescents  who have experienced traumatic events such as physical or sexual abuse, major loss, and natural disasters.

  2. The TSCC is customizable: The test features separate self-report profile forms for males and females, with items for ages 8-12 years on one side and items for ages 13-16 years on the other side. An alternate form, the TSCC-A, makes no reference to sexual issues.

  3. The TSCC is reliable and valid: It meets the new 2017 standards for use in Children’s Advocacy Centers.

  4. The TSCC has free online training. Get up to speed quickly with a short instructional video describing the administration, scoring, and interpretation of the TSCC—available at no charge on the PAR Training Portal.

  5. The TSCC is convenient. Administer and score with paper and pencil or 24/7 via PARiConnect, our online assessment platform.

According to new research conducted at Walter Reed Army Institute of Research in Silver Spring, Maryland, the proportion of soldiers using mental health services nearly doubled between 2003 and 2011. Furthermore, researchers found a small but significant decrease in the perceived stigma associated with seeking mental health services.

In 2003, only about 8 percent of soldiers sought mental health services. In 2011, about 15 percent of soldiers did so. Even with the increase in the number of soldiers seeking mental health help, researcher Phillip Quartana stated that two-thirds of soldiers with post-traumatic stress (PTSD) or major depression symptoms did not seek treatment between 2002 and 2011. More than 25 percent of active infantry soldiers from the conflicts in Afghanistan and Iraq, dating back to the beginning of the conflicts in 2001, met self-reported criteria for these diagnoses. While the number of soldiers seeking help has increased and the stigma associated with seeking mental health services has decreased, these results demonstrate that more progress is needed to increase soldiers’ use of mental health care services.

Researchers used data from active-duty personnel who completed Health-Related Behavior Surveys between 2002 and 2011. This study is the first to empirically examine trends concerning utilization of services and stigma across multiple wars.

The study was published online in the American Journal of Public Health.
Posttraumatic stress disorder (PTSD) now affects one in 29 Americans, reports Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, in a June 6 statement. An anxiety disorder, PTSD affects not only combat veterans but also crime and abuse victims, disaster survivors, first responders, and others who have experienced trauma in their lives.

Symptoms of PTSD can include sleep problems, irritability, anger, recurrent dreams about the trauma, intense reactions to reminders of the trauma, disturbances in relationships, and isolation. The good news is that PTSD is treatable, and new research is helping to identify the kinds of treatment that are most effective.

“The Department of Health and Human Services, along with the Departments of Veterans Affairs and Defense, are supporting new research to reveal the underlying causes of PTSD and related conditions, develop better tools to identify those at highest risk of developing the disorder, and develop new and better treatments and preventive interventions,” says Sebelius.

The National Institute of Mental Health is also funding research—including both evaluation and intervention studies—on a wide range of PTSD topics. Current NIMH studies are focused on:

  • Teens coping with parental military deployment

  • The effectiveness of a Web-based intervention for guardians of children whose one parent has murdered the other

  • The effects of stress in pregnancy

  • Cognitive behavioral treatment for PTSD in people with additional serious mental illnesses

  • Comparing behavioral therapies for treating adolescents with PTSD related to sexual abuse

  • The development of magnetic resonance imaging techniques for studying mood and anxiety disorders

  • Group intervention for interpersonal trauma

  • Prazosin for treating noncombat-trauma PTSD

  • Psychobiological mechanisms of resilience to trauma


To learn more about these studies, or for information and resources to share with your clients, visit the PTSD Web site at the NIMH.
Director John Huston’s film Let There Be Light, a documentary about the psychological issues of soldiers returning from World War II, has recently been restored and released by the National Archives and Records Administration. Produced by the U.S. Army in 1945, this controversial film was censored for more than three decades. By the time it was finally given a public screening in 1980, the quality of the then-available print was so poor that it was very difficult to view and understand. In this new restoration, the technical problems have been resolved, and many of us will now see this important piece of history for the first time.

Let There Be Light deals with “shell-shock,” or in today’s terms, post-traumatic stress disorder (PTSD), among returning soldiers. Huston, who is best known as the director of such classics as The Maltese Falcon (1941), Key Largo (1948), and The African Queen (1951), was serving as a major in the U.S. Army Signal Corps when he was given the assignment to create the documentary in June 1945. Its working title was The Returning Psychoneurotics. Although by current standards, the psychiatric methods and therapeutic “cures” are dated and perhaps unrealistic, the film captures some historically significant aspects of military psychiatric practice during the 1940s.

Huston later described the project:

I visited a number of Army hospitals during the research phase, and finally settled on Mason General Hospital on Long Island as the best place to make the picture. It was the biggest in the East, and the officers and doctors there were the most sympathetic and willing…. The hospital admitted two groups of 75 patients each week, and the goal was to restore these men physically, mentally and emotionally within six to eight weeks, to the point where they could be returned to civilian life in as good condition—or almost as good—as when they came into the Army…. I decided that the best way to make the film was to follow one group through from the day of their arrival until their discharge. (Source: National Film Preservation Foundation, Film Notes)


Let There Be Light was ground-breaking not only in its use of unscripted interview techniques, but also because of the mix of racial groups represented in the film. Although the U.S. military would remain largely segregated until President Truman’s executive order of 1948, a few Army hospitals had begun integrating in 1943. Huston’s film shows African American and white soldiers being treated side-by-side, an unusually progressive choice at that time.

To view this documentary now, visit the National Film Preservation Foundation and click on the link for Let There Be Light. And let us know what you think—leave a comment here to join the conversation!
What’s in a name? For young veterans and others coping with post-traumatic stress disorder, a name could mean the difference between seeking treatment and suffering alone. Psychiatrists and military officers are now considering the implications of a name change for PTSD in an effort to reduce the stigma associated with this diagnosis. The new name under consideration? Post-traumatic stress injury, or PTSI.

“No 19-year-old kid wants to be told he’s got a disorder,” said General Peter Chiarelli, in a May 5 interview with the Washington Post. Until his retirement in February of this year, Chiarelli was the nation’s second-highest ranking Army officer, and he led the effort to reduce the suicide rate among military personnel. He and other supporters of the name change believe that using the word “injury” instead of “disorder” will reduce the stigma that stops soldiers and others from seeking treatment. According to Chiarelli, “disorder” suggests a pre-existing condition that “makes the person seem weak.” “Injury,” on the other hand, is appropriate because the condition is caused by the experience of specific trauma, according to supporters of the change. Injuries, they point out, can often be healed with treatment.

This issue is coming to a head because the American Psychiatric Association is working on a new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), expected in May 2013. Not everyone is in favor of the name change; one of the major concerns, according to psychologist Sherrie Bourg Carter, is that “altering a diagnostic label may have far-reaching financial implications for health insurers and disability claims. Specifically, some insurers and government agencies may not be willing to reimburse mental health providers for a condition that isn’t considered a disease or disorder” (Psychology Today blog, May 6).

American Psychiatric Association President Dr. John Oldham has suggested that he would be open to considering the name change. “If it turns out that that [the word ‘injury’] could be a less uncomfortable term and would facilitate people who need help getting it, and it didn’t have unintended consequences that we would have to be sure to try to think about, we would certainly be open to thinking about it,” Oldham told PBS NewsHour in a December interview.

What do you think? Would a name change help reduce the stigma associated with post-traumatic stress and encourage people to seek the help they need? PAR wants to hear from you, so leave a comment and join the conversation!

 
According to a new study conducted at Princeton University, many survivors of 2005’s Hurricane Katrina are still struggling with poor mental health even today, years after the storm.

Lead researcher Christina Paxson and her team began this project in 2003 as a study of low-income adults enrolled in community college. They used sites around the country for their research, three of those sites were located in New Orleans. Their original questionnaire asked participants for their opinions on topics related to education, income, families, and health.

After Hurricane Katrina hit in August 2005, the researchers decided to continue to track the New Orleans-based participants because the type of information they had was very rare in disaster studies, as they already knew much about the individual’s mental and physical health. In most disaster studies, researchers are never able to determine if the participants are suffering because of the disaster or because they already had underlying conditions that would have led to poor mental health even before the disaster hit.

With data collected one year before, 7-19 months after, and 43-54 months post-Katrina, they found that although symptoms of posttraumatic stress and psychological distress declined over time, these symptoms were still high 43-54 months after the storm. They also found that damage to the home was an especially important predictor of chronic posttraumatic stress symptoms, with and without symptoms of psychological distress. Those individuals with higher earnings and better social support reported better outcomes in the long run, but results indicate that mental health issues still remain a concern for hurricane survivors.

Even four years after the storm, researchers found that about a third of participants still reported high levels of posttraumatic stress and about 30 percent reported suffering from psychological distress.

According to Paxson, “I think the lesson for treatment of mental health conditions is don’t think it’s over after a year. It isn’t.”

To read more about the study, see January’s issue of Social Science & Medicine.

What do you find most beneficial in working with survivors of traumatic events?
The National Defense Authorization Act recently passed by Congress omitted a key requirement, possibly making it easier for active-duty military personnel and veterans to receive mental health care.

Previously, mental health practitioners were required to be licensed in the state in which care was being administered. The removal of this provision means that military personnel and vets located anywhere in the US may be able to receive counseling through video teleconference technology from a mental health professional  located elsewhere.

A previous exemption allowed cross-state counseling only if both practitioner and patient were located on federal property, but the new law permits care to be provided at any location, including from a civilian location or even inside a patient’s home.

Limitations still exist, however. The delivery of care via telehealth into service members’ homes is not currently authorized under Tricare policy.

Nearly 20% of service members returning from Iraq and Afghanistan report symptoms of PTSD or major depression, according to a Rand Corporation study. And telehealth is a hot topic within the military—last year, the Department of Defense National Center for Telehealth and Technology launched an online educational tool that enables combat veterans to learn more about PTSD within a “second life”-type environment.

How do you feel about using telehealth technology to deliver PTSD therapy? What other changes must be made to make this type of counseling more accessible? Weigh in—we’d love to hear what you think.

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