Post Traumatic Stress Disorder and Abuse

BACKGROUND

Description

Post Traumatic Stress Disorder or PTSD is an anxiety syndrome with symptoms that develop after a person has been directly exposed to a highly traumatic event. Examples of trauma include being physically or sexually assaulted or the witnessing of a violent event. The severity of the symptoms are in part related to the severity of the trauma, the closeness of the individual to the event, and whether it is a single event or has been repeated over time (e.g. recurrent sexual abuse). The traumatic event may be re-experienced in a variety of distressing ways including intrusive and recurrent memories and dreams. The individual often withdraws or attempts to numb himself to the emotions involved. Symptoms of increased arousal including irritability, startle responses, and sleep disturbance, are also common. It is important to remember that the full syndrome of PTSD is at the most severe end of a continuum of symptoms of exposure to stress. Symptoms persisting less than a month are diagnosed as Acute Stress Disorder.

Unfortunately, exposure to extreme violence in our society is a common occurrence and every primary care clinician should be aware of its psychological impact. Preliminary evidence indicates that persons with developmental disabilities are much more likely to be victimized by violence and are more vulnerable to the experiencing of PTSD. This is in part related to the extraordinary high rates of abuse, especially sexual abuse, among individuals with developmental disabilities.

Occurrence

PTSD is a common and serious problem in our society. It is estimated that 9% of individuals experience PTSD and many more have sub-threshold symptoms. There is growing evidence that persons with developmental disabilities may be at special risk. Interpretation of crime statistics suggests that persons with developmental disabilities are more likely to be victims of crime of all types. Although accurate statistics are difficult to obtain, persons with disabilities may be at special risk for sexual abuse. It has been estimated that persons with disabilities are 2-4 times more likely to be sexually abused than individuals without disabilities. Several reasons have been proposed why the disabled segment of the population may be at higher risk:

Difficulty escaping an abusive situation because of mobility impairments
Presence of communication or physical impairments which limit the ability to defend themselves against a
perpetrator and disclose abuse
Dependency on others for essential care giving
Exposure to large numbers of caregivers
Tendency to be compliant from previous conditioning or training
Limited social opportunities with a desire for friendship and low self esteem
Isolation and lack of social supports
Lack of appropriate preventative education programs

Studies of adults in the general population suggest that as many as 25% of individuals exposed to significant trauma will develop PTSD; one study specifically indicated that 5 to 6% of adult men and 10 to 14% of adult women had experienced PTSD at some time in their lives. With the increased likelihood of exposure to abuse, it follows that PTSD and related anxiety and depressive symptoms are important and common problems in individuals with disabilities and are important considerations for clinicians as part of a differential diagnosis.

Characteristic Features

Condensation of DSM-IV criteria for PTSD:

Exposure to traumatic event involving loss of life, serious injury or threat to the physical integrity of self
or others.
The traumatic event is reexperienced in one or more of the following ways:
- Recurrent and intrusive memories
- Distressing dreams
- Sense of reliving the event including hallucinations and/or flashbacks
- Intense distress when exposed to reminders of the event
- Physiological changes related to reexperiencing the event
Avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by three or
more of the following:
- Avoiding thoughts of feelings associated with the event
- Avoiding situations that are reminders of the event
- Inability to recall significant aspects of the trauma
- Diminished interest or participation in activities
- Feelings of detachment or estrangement
- Decreased range of affect
- Sense of foreshortened future
Increased arousal
- Insomnia
- Irritability or outbursts of anger
- Difficulty concentrating
- Hypervigilance
- Exaggerated startle response

Diagnostic Considerations

Exposure to trauma might suggest diagnostic consideration of PTSD if there is an acute change in an individual’s behavior combined with symptoms of anxiety, for example:

Physiological signs of anxiety
New separation fears
Sleep changes
Withdrawal
New avoidance of certain people or situations
Emergence of new sexual behaviors

Many of the above PTSD symptoms may be difficult to elicit in individuals with developmental delays and the clinician will need to rely on observation and careful interviews of caregivers. However, in individuals with even basic verbal skills, the clinician should interview the patient alone and ask about potential abuse and trauma in a gentle and non-leading manner. Missed diagnoses are most commonly related to not asking about “sensitive” issues such as sexuality.

MEDICAL MANAGEMENT CONSIDERATIONS

Abuse and Neglect

In any clinical evaluation where abuse and neglect is suspected, a report must be made to the appropriate authorities. Every clinician should be aware of the reporting requirements for child, dependent adult, or elder abuse. Such reporting is mandatory. If the clinician has any questions about need to report or procedures the appropriate agency should be immediately consulted.

If a recent sexual assault is suspected the person should be referred to an emergency room or specialized evaluation unit for a specialized examination. In other situations the primary care physician should perform a careful physical examination.

In an abuse and neglect situation the safety of others in the home or living situation should be considered.

Treatment of PTSD

There is a serious lack of empirical research related to the treatment of PTSD in persons with developmental disabilities. Extending work with other groups and clinical experience suggest the following:

Psychotherapy in verbal individuals is the primary approach
Exploration of the traumatic event through verbal description and/or drawings is important. The tendency to “not
talk about it” should be avoided. This should of course be geared to the person’s cognitive abilities.
Cognitive-behavioral techniques may be helpful. These may include relaxation and desensitization.
Medications may be a helpful adjunct, particularly in non-verbal individuals or if overwhelming anxiety or
co-morbid depression develop (see below)
Family and/or caregiver involvement is important for education and support and to avoid inappropriate
interventions (e.g. isolating an individual at their residence because they are crying and upset)
Normalization of behavior is important (e.g. attending school, work programs etc.)

Medical Management

A variety of medication strategies have been employed in the treatment of PTSD. The general goal is to target core symptoms of PTSD and associated symptoms of depression or anxiety, allowing the person to utilize effective coping strategies and process the traumatic event rather than using avoidance behaviors.

Probably the first choice is treatment with an SSRI antidepressant, for example:

Sertraline (Zoloft; FDA-approved)
Paroxetine (Paxil or Paxil CR; FDA-approved; good for sleep)

Nefazodone (Serzone) has been effective in open trials and also may aid in sleep disturbance; Trazodone (Desyrel) and Clonidine (Catapres) have also been used successfully for sleep disturbance

Sedation with neuroleptics should be avoided

Benzodiazepines should be avoided, and Xanax was shown to be no more effective than a placebo

REFERENCES

American Academy of Child and Adolescent Psychiatry. (1998). Practice Parameters for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder.
Journal of the American Academy of Child and Adolescent Psychiatry, 37(10), 4-26.

American Academy of Child and Adolescent Psychiatry. (1999). Your Adolescent: Emotional, Behavioral, and Cognitive
Development from Early Adolescence through the Teen Years, Pruitt D.B., (Ed.) New York: Harper Collins.

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental

Disorders, 4^th edition (DSM-IV). Washington DC: American Psychiatric Association

Borus, N. (1999). (Ed.) Psychiatric and Behavioural Disorders in Developmental Disabilities and Mental
Retardation. Cambridge: Cambridge University.

Breslau, N. (2001). The Epidemiology of Posttraumatic Stress Disorder: What is the Extent of the Problem? Journal of
Clinical Psychiatry, 16(17), 16-22.

Dosen, A., Day, K. (2001). (Eds.) Treating Mental Illness and Behavior Disorders in Children and Adults with Mental
Retardation. Washington: American Psychiatric.

Dykens, E.M. (2000). Psychopathology in Children with Intellectual Disabilities. Journal of Child Psychology and
Psychiatry, 41, 407-417.

Easter Seals Superior California. (2000). Technical Assistance Manual for Mandated Reporting of Suspected Crimes Against Victims with Disabilities (
www.eastersealsca.com)

Firth, H., Balogh, R., Berney, T., Bretherton, K., Graham, S., Whibley, S. (2001). Psychopathology of Sexual Abuse in Young People with Intellectual Disability.
Journal of Intellectual Disability Research, 45(3), 244-252.

Hageman, I., Andersen, H.S., Jorgensen, M.B. (2001). Post-traumatic Stress Disorder: A Review of Psychobiology and Phamacotherapy.
Acta Psychiatrica Scandinavica, 104, 411-422.

Lumley, B.A., Miltenberger, R.G. (1997). Sexual Abuse Prevention for Persons with Mental Retardation. American
Journal on Mental Retardation, 101(5), 459-472.

Madrid, A.L., State, M.W. (2000). Pharmacologic Management of Psychiatric and Behavioral Symptoms in Mental Retardation.
Child and Adolescent Psychiatric Clinics of North America, 9, 225-243.

Mansell, S., Sobsey, D., Moskal, R. (1998). Clinical Findings Among Sexually Abused Children with and without Developmental Disabilities.
Mental Retardation, 36(1), 12-22.

Parker, S., Zuckerman, B. (1995). (Eds.) Behavioral and Developmental Pediatrics: A Handbook for Primary
Care. Boston: Little, Brown.

Pine, D.S., Cohen, J. (2002). Trauma in Children and Adolescents: Risk and Treatment of Psychiatric Sequelae. Biological
Psychiatry, 51(7), 519-531

Reiss, S., Aman, M.G., (Eds.) (1998). Psychotropic Medications and Developmental Disabilities: The International
Consensus Handbook. Columbus: Ohio State University.

Rothbaum, B.O., Marshall, R., Foa, E.B., Lindy,J., Mellman, L. (2000). Posttraumatic Stress Disorder. In: Treatments
of Psychiatric Disorders. (pp.1539-1566) 3
^rd Ed. Gabbard, (Eds.) American Psychiatric Publishing: Washington, DC,

Rush, J., Frances, A. (Eds.) (2000). Expert Consensus Guideline Series: Treatment of Psychiatric and Behavioral Problems in Mental Retardation.
American Journal of Mental Retardation, 105(3), 159-226.

Ryan, R. (1994). Posttraumatic Stress Disorder in Persons with Developmental Disabilities. Community Mental Health Journal 30(1): 45-54

Sullivan, P.M., Knutson, J.F. (2000). Maltreatment and Disabilities: A Population-based Epidemiological Study. Child
Abuse and Neglect, 24(10), 1257-1273.

Szymanski, L., King, B.H. (1999). Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Mental Retardation and Comorbid Mental Disorders.
Journal of the American Academy of Child and Adolescent Psychiatry, 38(12), 5-31.

Szymanski, L., King, B.H., Goldberg, B., et al. (1998). Diagnosis of Mental Disorders in People with Mental Retardation. In:
Psychotropic Medications and Developmental
Disabilities (pp. 3-17)The International Consensus Handbook; Reiss, S., Aman, M.G., (Eds.) Columbus: Ohio State University Press.

Volkmar, F.R., Dykens, E. (2002). Mental Retardation. In: Child and Adolescent Psychiatry: A Comprehensive
Textbook (3^rd ed., pp. 603-611) Lewis, M., (Ed.) Philadelphia: Lippincott Williams & Wilkins.

Yehuda, R. (2002). Current Concepts: Post-Traumatic Stress Disorder. New England Journal of Medicine,
346(2), 108-114.

RESOURCES FOR FAMILIES

American Academy of Child and Adolescent Psychiatry

3615 Wisconsin Avenue N.W.

Washington, D.C. 20016-3007

202-966-7300

http://www.aacap.org

The Arc (formally Association for Retarded Citizens)

500 East Border Street, Suite 300

Arlington, Texas 76010

617-261-6003

800-433-5225

Home

California Department of Developmental Services

P.O. Box 944202

Sacramento, CA 94244-2020

916-654-1690

http://www.dds.ca.gov

California Regional Centers

915-654-1958

http://www.dds.ca.gov/rc/RCinfo.cfm

California Alliance for the Mentally Ill

1111 Howe Avenue, Suite 475

Sacramento, CA 95825-8541

916-567-0163

800-950-NAMI

Fax: 916-567-1757

[email protected]

http://www.nami.org

http://namicalifornia.org

National Mental Health Association Information Center

2001 North Beauregard Street, 12^th floor

Alexandria, VA 22311

703-684-7722

800-969-6642

Fax: 703-684-5968

[email protected]

http://www.nmha.org

Association of University Centers on Disabilities

8630 Fenton Street, Suite 410

Silver Spring, MD 20910-3803

301-588-8252

http://www.aucd.org

The National Association for the Dually Diagnosed

132 Fair Street

Kingston, NY 12401

800-331-5362

http://www.thenadd.org

Project MED (Medical Education for Consumers)

http://www.projectmed.org

The Tarjan Center for Developmental Disabilities at UCLA

http://www.tarjancenter.ucla.edu

California Mental Health and Developmental Disabilities Center

http://www.mhddc.ucla.edu

American Psychiatric Association

1400 K Street N.W.

Washington, DC 20005

888-337-7924

http://www.psych.org

ADVISORY COMMITTEE

Theodore A. Kastner, M.D., M.S.

Leonard Magnani, M.D., Ph.D.

Felice Weber Parisi, M.D., M.P.H.

Terrance D. Wardinsky, M.D.

PUBLICATION INFORMATION

Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.