Case Study: Elaine: PTSD, SF

• General vulnerability factor: trait anxiety or anxiety proneness (Herrema, et al. 2001).

Case Study: Elaine

Post Traumatic Stress Disorder

& Diathesis Stress Model

Diathesis Stress Model

Biological & psychological diatheses interact with environmental factors, stressors, to determine the likelihood that a person will exhibit abnormal behavior.

Background History: Early Trauma

Initial Traumatic Event

Second Traumatic Event

Hyperarousal & Hypervigilance

Intrusive Symptoms

Avoiding Trauma-linked Stimuli

Trauma-linked Negative Emotions

& Cognitions

Distress & Impairment: Social

Distress & Impairment: Emotional

Train Crash

• Her head struck a metal pole, knocking her out.

• Horrified that she was bleeding to death

• Feared for her survival

• Childhood in Alabama during the civil rights movement.

• Witnessed marches and nonviolent protests that were often met with threats and violence.

• Among first African-American students to attend a desegregated  school

• Jailed for a day for civil disobedience

• At home she experienced intrusive vivid memories of the subway car or the emergency room.

• Trauma related dreams that contained images of her subway or emergency room experience

• Taking the bus or subway was simply out of the question. The very thought of getting on a train made her shudder.

• Elaine turned every conversation back to her “horrible experience,” and her friends began to lose patience. 

• Elaine pushed her friend out of her life

• Elaine became increasingly angry, nasty, and cynical

• A friend described her as irritable and blaming of others.

Hospital

• Elaine was terrified as she observed gruesome scenes of people being brought in as a result of stabbings, shootings, drug overdoses.

• Elaine spent 3 hours in a highly anxious state, restrained by the straps on the gurney,

• Overcome by her fears, she even wondered whether she was being taken away to be raped or killed by the hospital orderly.  

• Extreme startle response: receptionist’s voice, Elaine practically jumped out of her seat.

• Sleep disturbance: she now found herself waking frequently from dreams

• Hypervigilance: High anxiety about crossing the street

• Persistent negative emotions: increasingly angry, nasty, and cynical

• Thoughts about the dangers of the world
• Almost exclusively on the prospect of dying or being raped or murdered.

Life Threatening Event

Perceived Life Threatening Event

Treatment: Cognitive Behavioral Therapy

Elaine: Exposure with Insight

Insight & Cognitive Restructuring

Cognitive Treatment

Behavioral Treatment:

In Vivo Exposure

Imaginal Exposure

• The behavioral approach involves exposing the person—with either in vivo or imaginal exposure—to anxiety-provoking stimuli.

• Dr. Fehrman suggested that occasional episodes of loss of control are a normal part of life and that people are not necessarily diminished by their occurrence.

• A most troubling element of the whole experience was the sense of loss of control, being at the mercy of various ambulance and hospital workers and not being able to fend for herself.

• Repeatedly exposed to "real life" anxiety provoking stimuli, the subjects of their PTSD related fears and thoughts.

• Directly challenges the accuracy of the individual’s negative cognitions with the purpose to bring about a reduction in the fearful reactions.

• Used to help clients react less fearfully when recalling the original trauma.

• The individual repeatedly visualizes the entire sequence of events involved in the trauma for a long period, on a repeated basis.

• A hierarchy of anxiety-provoking situations, ranging from the least to most threatening, is constructed by the client and therapist.

• Elaine recalled a similar experience during her adolescence, when she had once been in the hands of the police while jailed for a day for civil disobedience
• She had later been able to view that episode as a transient interlude in an otherwise independent existence.

• She drew a direct connection to her childhood experience during the civil rights movement when physical and mental quickness were her most prized possessions

• The cognitive approach, called cognitive restructuring, guides the individual to think differently about the trauma itself and about possible current dangers.

• In one cognitive strategy, a client might be guided to practice less catastrophic interpretations of the trauma, often in connection with exposure exercises. 

• The individual is then given assignments to enter these situations and to remain there for a time, usually until he or she has a significant drop in anxiety. E as Ex

• The purpose of the exposure is to desensitize the client to the memory of the trauma.

• Elaine realized that her traumatic experience had dealt a severe blow to this most precious aspect of her self-image, a sense of control.

• She said she could now see how it might be possible to view the recent accident in a similar light.

Biological Diathesis: Genetics

Vulnerabilities

Psychological Diathesis

What Was Elaine's Diathesis?

• Childhood experiences led to a high need to be in control

• Did Elaine experience a psychological predisposition or vulnerability to PTSD?

Did she have an apparent biological or psychological predisposition or vulnerability for PTSD?

• Elaine experienced a dysfunction interpretation of her traumas to mean that she had lost all control over her life

• Biological vulnerability:
• genetic factors and / or
• brain dysfunction

• Psychological vulnerability:
• dysfunctional interpretation and reaction to environmental factors
• dysfunctional beliefs

Previous exposure to trauma is associated with a greater risk

of PTSD from subsequent trauma (Breslau, Chilcoat, Kessler, & Davis, 1999).

• Victims who perceive that future negative events are uncontrollable are much more likely to have severe PTSD symptoms than those victims who perceive some future control (Basoglu & Mineka, 1992).

• Biological: genetics and/or brain dysfunction?

• Psychological: dysfunctional beliefs and /or dysfunctional interpretation of environmenal events?

Diathesis: History of Previous Trauma N

Diathesis: High Need for Control

Perception of Loss of Control

PTSD

What theoretical perspectives are applicable

in this case study?

What Were Elaine's Stress(or)?

Stress: Environmental Factors (stressors)

• Behavioral Perspective, psychological:
• Use of behavioral treatment, In-vivo Exposure, Imaginal Exposure

Did she experience specific and significant stressors that could contribute to the devlopment of PTSD?

Stressor: Traumatic Experiences

• Cognitive Perspective, psychological:
• Use of cognitive treatment in addressing dysfunctional thinking, cognitive restructuring.

• Stress: negative emotional experience accompanied by biochemical, physiological, cognitive, and behavioral responses aimed at changing or adjusting to the stressor

• Stressor: any event that produces tension or other negative emotions
• Example: Research Paper due at midnight

Stress: Feelings of fear and vulnerability (distress)

Dysfunction: withdrawal and avoidance

• Socio-Cultural Perspective, social
• Socio: social support from friends
• Cultural: experiences during the Civil Rights Movement were sometimes traumatic and led her to develop a high need for control over her life.

PTSD

DSM 5: Posttraumatic Stress Disorder

A. Person is exposed to a traumatic event—death or threatened death, severe injury, or sexual violation.

B. Person experiences at least 1 of the following intrusive symptoms:   

1. Repeated, uncontrolled, and distressing memories   

2.Repeated and upsetting trauma-linked dreams  

3. Dissociative experiences such as flashbacks   

4. Significant upset when exposed to trauma-linked cues   

5. Pronounced physical reactions when reminded of the event(s).

C. Person continually avoids trauma-linked stimuli.

D. Person experiences negative changes in trauma-linked cognitions and moods, such as being unable to remember key features of the event(s) or experiencing repeated negative emotions.

E. Person displays conspicuous changes in arousal and reactivity, such as excessive alertness, extreme startle responses, or sleep disturbances.

F. Symptoms lasting more than a month

G.Person experiences significant distress or impairment,(Based on APA, 2013.)

Does Elaine meet criteria for PTSD?