Anxiety and related disorders Case 6
Imagery, Imagery treatment and PTSD
Problem statement: “What is PTSD and how can you treat it?”
Learning goals:
Part 1:
I. What is PTSD?
II. What is a fragmented memory and how does it maintain PTSD and flashbacks?
III. What is the difference between patients with childhood traumas vs adulthood?
Part 2:
IV. What is EMDR, Imaginal exposure and imagery rescripting treatment?
Part 3:
V. What are flashforwards and encapsulated beliefs? (examples disorders)
VI. How can current intrusions be linked with past aversive events/memories?
What is PTSD?1
Different types of trauma:
Acute trauma; a single incident.
Chronic trauma; repeated and prolonged (e.g., domestic violence or abuse).
Complex trauma; exposure to varied and multiple traumatic events, often of an invasive,
interpersonal nature.
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have
experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist
act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.
DSM-V
PTSD is classified withing ‘Trauma- and stressor-related disorders’.
A. Exposure to actual or threatened death, serious injury, or sexual violence in ≥1 ways:
(these are the official criteria for a trauma)
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or friend.
In cases of actual or threatened death of a family member or friend, the event(s) must have
been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
(e.g., 1st responders collecting human remains, police repeatedly exposed to details of child abuse).
→ This doesn’t apply through exposure though electronic media or movies.
B. Presence of ≥1 intrusion symptoms associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are related
to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring.
4. Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble
an aspect of the traumatic event(s).
1 Bovin, et al. (2014). Posttraumatic Stress Disorder.
, C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the
traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities,
objects, situations) that arouse distressing memories, thoughts, or feelings.
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by ≥2 of the following:
1. Inability to remember an important aspect of the event(s) (due to dissociative amnesia).
2. Persistent and exaggerated negative beliefs or expectations about oneself/others/ world.
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or love).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by ≥2 of the following:
1. Irritable behavior and angry outbursts; verbal or physical aggression toward people or
objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep, or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, E) is >1 month.
G. The disturbance causes clinically significant distress or impairment functioning.
H. The disturbance is not attributable to physiological effects of a substance or medical condition.
Specifiers:
PTSD-criteria with dissociative symptoms:
1. Depersonalization – feeling detached from one’s mental processes or body; like you’re an
outside observer of yourself.
2. Derealization – experiences of unreality of surroundings; like you’re dreaming or distorted.
PTSD-criteria with delayed expression:
The PTSD-criteria aren’t fully met until ≥6 months after the event, although the onset and
expression of some symptoms are immediate.
Why PTSD isn’t an anxiety disorder:
1. PTSD can include internalizing AND externalizing feelings, like aggressiveness.
→ A substantial minority has externalizing PTSD; so, PTSD as an anxiety disorder did not fit
these patients properly.
2. Different brain areas involved in the process of PTSD.
3. Anxiety can include worries from the future, PTSD includes worries about the past.
4. Fear does not always play a role in PTSD.
Subtypes
1. Internalizing PTSD (axis-I comorbidities)
- Characterized by the tendency to direct distress inwardly.
- Expression: feelings of shame, anxiety, avoidance, and depression.
Imagery, Imagery treatment and PTSD
Problem statement: “What is PTSD and how can you treat it?”
Learning goals:
Part 1:
I. What is PTSD?
II. What is a fragmented memory and how does it maintain PTSD and flashbacks?
III. What is the difference between patients with childhood traumas vs adulthood?
Part 2:
IV. What is EMDR, Imaginal exposure and imagery rescripting treatment?
Part 3:
V. What are flashforwards and encapsulated beliefs? (examples disorders)
VI. How can current intrusions be linked with past aversive events/memories?
What is PTSD?1
Different types of trauma:
Acute trauma; a single incident.
Chronic trauma; repeated and prolonged (e.g., domestic violence or abuse).
Complex trauma; exposure to varied and multiple traumatic events, often of an invasive,
interpersonal nature.
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have
experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist
act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.
DSM-V
PTSD is classified withing ‘Trauma- and stressor-related disorders’.
A. Exposure to actual or threatened death, serious injury, or sexual violence in ≥1 ways:
(these are the official criteria for a trauma)
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or friend.
In cases of actual or threatened death of a family member or friend, the event(s) must have
been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
(e.g., 1st responders collecting human remains, police repeatedly exposed to details of child abuse).
→ This doesn’t apply through exposure though electronic media or movies.
B. Presence of ≥1 intrusion symptoms associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are related
to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring.
4. Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble
an aspect of the traumatic event(s).
1 Bovin, et al. (2014). Posttraumatic Stress Disorder.
, C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the
traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities,
objects, situations) that arouse distressing memories, thoughts, or feelings.
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by ≥2 of the following:
1. Inability to remember an important aspect of the event(s) (due to dissociative amnesia).
2. Persistent and exaggerated negative beliefs or expectations about oneself/others/ world.
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or love).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by ≥2 of the following:
1. Irritable behavior and angry outbursts; verbal or physical aggression toward people or
objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep, or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, E) is >1 month.
G. The disturbance causes clinically significant distress or impairment functioning.
H. The disturbance is not attributable to physiological effects of a substance or medical condition.
Specifiers:
PTSD-criteria with dissociative symptoms:
1. Depersonalization – feeling detached from one’s mental processes or body; like you’re an
outside observer of yourself.
2. Derealization – experiences of unreality of surroundings; like you’re dreaming or distorted.
PTSD-criteria with delayed expression:
The PTSD-criteria aren’t fully met until ≥6 months after the event, although the onset and
expression of some symptoms are immediate.
Why PTSD isn’t an anxiety disorder:
1. PTSD can include internalizing AND externalizing feelings, like aggressiveness.
→ A substantial minority has externalizing PTSD; so, PTSD as an anxiety disorder did not fit
these patients properly.
2. Different brain areas involved in the process of PTSD.
3. Anxiety can include worries from the future, PTSD includes worries about the past.
4. Fear does not always play a role in PTSD.
Subtypes
1. Internalizing PTSD (axis-I comorbidities)
- Characterized by the tendency to direct distress inwardly.
- Expression: feelings of shame, anxiety, avoidance, and depression.
