Department of Psychology

Posttraumatic stress disorder (PTSD)

Trauma

There are different classification systems for mental disorders in the research. In this, symptoms, probability of occurrence and processes of the specific clinical pictures are described. The most used system is the diagnostic and statistical manual of mental disorders in the fifth version (DSM-%, Falkai & Wittchen, 2015). One of these categories is the trauma and stress related disorders. It is characterized by traumatic and stressful experiences which lead to mental stress symptoms like fears, anger or dissociations (separation of perception and reality). The following five subcategories belong to the trauma and stress related disorders:

• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
• Posttraumatic Stress Disorder
• Acute Stress Disorder
• Adjustment Disorders

What is PTSD?

PTSD is a subgroup of trauma and stress related disorders. Being this, a traumatic event underlays. A traumatic event is a confrontation with the actually or imminent death, a serious injury or sexual assault. There are two different types of traumata. Typ-1-traumata are short and typ-2-traumata are long-lasting and recur (Rosner, 2008). Additionally, there is the division into accidental and interpersonal trauma reasons. You can see a short overview in table 1.

Table 1. Examples for the different trauma kinds (based on Maercker, 2013).

How can you diagnose a PTSD?

8 criteria need to be fulfilled to get the diagnose PTSD (Falkai & Wittchen, 2015). In the diagnostic of PTSD in childhood, you need to watch out for symptoms during play behavior.

1. The affected person needs to be exposed to a traumatic event. It is not necessary, that the affected person was exposed to it directly. If the events (a) were personally witnessed (e.g. standing next to an explosion, where people are killed) (b) happened to a family member or a close friend (e.g. call, where the death through an accident is told) or (c) Are a recurrent or an extreme confrontation with details of a traumatic event (e.g., first responders, collecting body parts) PTSD can be a consequence. This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.
2. The traumatic event is persistently re-experienced, for example with involuntary memories (intrusions), traumatic nightmares, dissociative reactions (e.g. flashbacks) or intense or prolonged distress after exposure to traumatic reminders.
3. The person shows persistent effortful avoidance of distressing trauma-related stimuli after the event. For example of thoughts or feeling or external reminders like people or places.
4. There are negative alterations in cognitions and mood that began or worsened after the traumatic event. These can be dissociative amnesia, distorted negative beliefs and expectations about oneself or the world and persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
5. The trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event, e.g. like hypervigilance, sleep disturbance or irritable or aggressive behavior.
6. Persistence of symptoms for more than one month.
7. Significant symptom-related distress or functional impairment (e.g., social, occupational).
8. Disturbance is not due to medication, substance use, or other illness.

Frequency of PTSD?

Not everybody, experience a traumatic event, develop a PTSD. Following DSM-4 criteria is the chance to fall sick of PTSD once in a life (= lifetime prevalence) in the USA around 9%. In Europe and most of the Asian, African or Latin-American countries, the lifetime prevalence is around 0.5% and 1%. A research study about the prevalence of PTSD in youth in Germany showed, that 1.3% of youth (14-24 years) undergo a PTSD. Accordingly, there are cultural differences in the development of PTSD.

Are there people more likely developing a PTSD than others?

Especially vulnerable are special occupation groups, which are constant imperiled to traumatic events (e.g. soldiers). Also, survivors of a rape, a military action, imprisonment and genocide are more often affected. Adverse preconditions are among other things emotional problems in infancy, actual mental disorders, a low socio-economic status, a low education level, a low IQ, being a woman and a low age at the time of the trauma.

What is the PTSD treatment like?

It is recommended, to have an accurate observation during the acute phase. This should be complemented by social support, enlightenment and mental hygiene. In general, you can divide the PTSD treatment into 3 phases:

1. Stabilization: to build up intrinsic and exterior safety, to learn different relaxation skills,
2. Dealing with trauma: confrontation and
3. Integration: classify in biography and expansion of perspective (Rosner, 2008)

There are a lot of studies in the cognitive behavior therapy (CBT) and in the narrative exposition therapy (NET), telling both as being promising in the treatment of PTSD (Rosner, 2008).

Sleep (disorders) and PTSD

Changed sleep is a possible diagnostic criterion of PTSD, so because of the disorder definition you can expect a link in between. More over a lot of affected people have flashbacks of the traumatic event in their dreams, especially in the age of children and youth. A nightmare disorder can follow out of the repetitive experience, which can influence the sleeping quality and quantity. This can lead to a worse general state and thus compound the PTSD symptoms ? the affected person is in a vicious circle.

The link between sleep and PTSD can be used to help the affected person. There are learning processes while we sleep. We digest day experiences and classify it into our previous experiences. This is called mind consolidation. By implication, this process can be used to avoid the consolidation of traumatic mind consolidations, for example through sleep deprivation (Walker & van der helm, 2009). Moreover, a treatment of the sleep problem can lead to an improvement of PTSD symptoms.

Refugees and PTSD

In 2014, there were more than 60 million people worldwide fleeing ? this is the highest rate ever being recorded. (Statistisches Bundesamt, 2005). From January to July 2016 have been 479.620 asylum applications only in Germany (Bundesamt für Migration und Flüchtlinge, 2016). A lot of refugees saw war, removal, partly imprisonment and torment.

Especially children suffer from leaving the home country, having a troublesome fleeing and finally to settle down in the foreign country. The prevalence rate for PTSD in refugee children is in between 14 and 60 percent. A lot of them

• had to witness body abuse (17.7%-46.3%),
• were physical abused (14.4%-78%),
• were sexual abused (4.8%),
• lost a relative (40.9%-52.7%) or a friend (20.9% (Metzner, Reher, Kindler & Pawils, 2016).

Children and adolescents put in one third of all asylum seekers with in total 138.00 applications (Metzner, Reher, Kindler & Pawils, 2016). 77.645 came as unaccompanied refugee children to Germany (Statistisches Bundesamt, 2016).

The support situation for refugee children is sensitive. In 2015, only 13500 refugees could be supplied in psychosocial centers ? which does not cover the real requirement (Bundesweite Arbeitsgemeinschaft der psychosozialen Zentren für Flüchtlinge und Folteropfer, 2016). Next to the language barrier are bureaucratic obstacles and to less therapy place the reasons for the undersupply. Besides, there are no research based evaluated therapy concepts for the treatment of traumatized refugees.

This is why the outpatient clinic for children and adolescents (HAKIJU) of the University of Bielefeld has a position for the treatment of traumatized refugee children. (More information will follow)

Literatur

Bundesamt für Migration und Flüchtlinge (2016). Aktuelle Zahlen zu Asyl (Juli 2016). URL: http://www.bamf.de/SharedDocs/Anlagen/DE/Downloads/Infothek/Statistik/Asyl/aktuelle-zahlen-zu-asyl-juli-2016.pdf?__blob=publicationFile

Bundesweite Arbeitsgemeinschaft der Psychosozialen Zentren für Flüchtlinge und Folteropfer (2016). Stellungnahme der Bundesweiten Arbeitsgemeinschaft der Psychosozialen Zentren für Flüchtlinge und Folteropfer. URL: https://www.bundestag.de/blob/426680/5813a4bcc9e1c8f6234688c256c8ebf4/bundesweite-arbeitsgemeinschaft-psychosozialer-zentren-fuer-fluechtlinge-und-folteropfer-e--v---baff--data.pdf

Döpfner, M. & Zaudig, M. (2015). Trauma- und belastungsbezogene Störungen. In M. Döpfner und M. Zaudig (Hrsg.), Diagnostisches und Statistisches Manual Psychischer Störungen DSM-5 (361-396). Göttingen: Hogrefe.

Falkai, P. & Wittchen, H.U. (2015). Diagnostisches und Statistisches Manual Psychischer Störungen DSM-5. Göttingen: Hogrefe.

Maercker, A. (Hrsg.) (2013). Posttraumatische Belastungsstörungen (4. Aufl.). Berlin: Springer.

Rosner, R. (2008). Posttraumatische Belastungsstörung. In F. Petermann (Hrsg.), Lehrbuch der Klini-schen Kinderpsychologie, 6. Auflage. Göttingen: Hogrefe.

Statistisches Bundesamt (2015). UNHCR: 60 Millionen Menschen auf der Flucht. URL: https://www.destatis.de/DE/ZahlenFakten/ImFokus/Internationales/Fluechtlinge2014Deutschland.html

Statistisches Bundesamt (2016). Unbegleitete Einreisen Minderjähriger aus dem Ausland lassen Inobhutnahmen 2015 erheblich ansteigen. URL: https://www.destatis.de/DE/PresseService/Presse/Pressemitteilungen/2016/08/PD16_268_225.html

Walker M.P. & van der Helm, E. (2009). Overnight therapy? The role of sleep in emotional brain processing . Psychological Bulletin, 135(5), 731?748.