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the lasting effects of childhood trauma evidence based interventions can help address ptsd other symptoms in adulthood hildhood trauma which is also called adverse child hood experiences aces can have ...

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          The lasting effects of childhood trauma
                                                                        Evidence-based interventions 
                                                                        can help address PTSD, other 
                                                                        symptoms in adulthood
                                                                               hildhood trauma, which is also called adverse child-
                                                                               hood experiences (ACEs), can have lasting detrimen-
                                                                       Ctal effects on individuals as they grow and mature 
                                                                        into adulthood. ACEs may occur in children age ≤18 years if 
                                                                        they experience abuse or neglect, violence, or other traumatic 
                                                                        losses. More than 60% of people experience at least 1 ACE, 
                                                                        and 1 in 6 individuals reported that they had experienced ≥4 
                                                                               1
                                                                        ACEs.  Subsequent additional ACEs have a cumulative dete-
                                                                        riorating impact on the brain. This predisposes individuals to 
                                                                        mental health disorders, substance use disorders, and other 
                                                                        psychosocial problems. The efficacy of current therapeutic 
                                                                        approaches provides only partial symptom resolution. For 
                                                                    OLGA_Z/GETTY IMAGESsuch individuals, the illness load and health care costs typi-
                                                                                                               1,2 
                                                                        cally remain high across the lifespan.
          Shikha Verma, MD, FAPA                                           In this article, we discuss types of ACEs, protective factors 
          Medical Director, Northern California                         and risk factors that influence the development of posttrau-
          Evolve Treatment Centers                                      matic stress disorder (PTSD) in individuals who experience 
          Danville, California                                          ACEs, how ACEs can negatively impact mental health in 
          Assistant Professor
          Department of Psychiatry and Behavioral Health                adulthood, and approaches to prevent or treat PTSD and 
          Rosalind Franklin University of Medicine and Science          other symptoms.
          North Chicago, Illinois 
          Ruchita Agrawal, MD, FAPA
          Associate Chief Medical Officer, Adult Services               Types of trauma and correlation with PTSD
          Seven Counties Services 
          Louisville, Kentucky                                          ACEs can be indexed as neglect or emotional, physical, or sex-
                                                                        ual abuse. Physical and sexual abuse strongly correlate with 
                                                                                                    3
                                                                        an increased risk of PTSD.  Although neglect and emotional 
                                                                        abuse do not directly predict the development of PTSD, these 
                                                                        Disclosures
                                                                        The authors report no financial relationships with any companies whose products are mentioned 
               Current Psychiatry                                       in this article, or with manufacturers of competing products.
         18 March 2021                                                  doi: 10.12788/cp.0101
               experiences foretell high rates of lifelong           Table 1
               trauma exposure and are indirectly related to        PTSD: Protective factors  
               late PTSD symptoms.4,5 ACEs can impede an            and risk factors
               individual’s cognitive, social, and emotional                                                                 MDedge.com/psychiatry
               development, diminish quality of life, and          Protective factors
                                       6                              Being male (more men than women are 
               lead to an early death.  The lifetime preva-
                                                 7                    exposed to trauma, but PTSD is twice as 
               lence of PTSD is 6.1% to 9.2%.  Compared               common in women)
               with men, women are 4 times more likely to             A strong relationship with family and peers
                                                            7
               develop PTSD following a traumatic event.  
                  The development of PTSD is influenced               Resilience and hope
               by the nature, duration, and degree of                 Limited genetic predisposition to psychiatric 
               trauma, and age at the time of exposure                illness
               to trauma. Children who survive complex             Risk factors 
               trauma (≥2 types of trauma) have a higher              Severity and duration of trauma
               likelihood of developing PTSD.8 Prolonged              Age at trauma
               trauma exposure has a more substantial                 Type and number of traumatic experiences
               negative impact than a one-time occurrence.                                                             Clinical Point
               However, it is an erroneous oversimplifica-            Severity of initial response to trauma
               tion to assume that each type of ACE has an            General childhood adversity                      ACEs can impede 
                                         6                            Reported childhood abuse                         cognitive, social, 
               equally traumatic effect.
                                                                      Gender                                           and emotional 
               Factors that protect against PTSD                      Low socioeconomic status                         development, 
                                                                      Low education                                    diminish quality of 
               Factors that can protect against developing            First-degree relative with a history of          life, and lead to an 
                                           7
               PTSD are listed in Table 1.  Two of these are          depression, other psychiatric illness, or        early death
               resilience and hope.                                   substance use
                  Resilience is defined as an individual’s            Single, divorced, widowed, or socially 
                                                             9 
               strength to cope with difficulties in life.            withdrawn
               Resilience has internal psychological char-            Inadequate family and peer support
               acteristics and external factors that aid in        PTSD: posttraumatic stress disorder
               protecting against childhood adversities.10,11      Source: Reference 7
               The Brief Resilience Scale is a self-assess-
               ment that measures innate abilities to cope, 
               including optimism, self-efficacy, patience, 
                                 12,13
               faith, and humor.      External factors associ-    PTSD. Some of these factors are outlined in 
                                                                           7
               ated with resilience are family, friends, and      Table 1.
                                     11,13
               community support.
                  Hope can help in surmounting ACEs. The 
               Adult Hope Scale has been used in many             Pathophysiology of PTSD
               studies to assess this construct in individuals    Multiple brain regions, pathways, and 
                                             13
               who have survived trauma.  Some studies            neurotransmitters are involved in the 
               have found decreased hope in individuals           development of PTSD. Neuroimaging has 
               who sustained early trauma and were diag-          identified volume and activity changes of 
               nosed with PTSD in adulthood.14 A study            the hippocampus, prefrontal cortex, and 
               examining children exposed to domestic vio-        amygdala in patients with early trauma 
               lence found that children who showed high          and PTSD. Some researchers have sug-                 Discuss this article at  
               hope, endurance, and curiosity were better         gested a gross reduction in locus coeruleus          www.facebook.com/ 
                                             15                                                                        MDedgePsychiatry
               able to cope with adversities.                     neuronal volume in war veterans with a 
                                                                  likely diagnosis of PTSD compared with 
                                                                  controls.16,17 In other studies, chronic stress 
               PTSD risk factors                                  exposure has been found to cause neuro-
               Many individual and societal risk factors          nal cell death and affect neuronal plasticity           Current Psychiatry
                                                                                                   18                          Vol. 20, No. 3
               can influence the likelihood of developing         in the limbic area of the brain.                                          19
                                                                                                   continued on page 24
                                       continued from page 19
                                          Table 2
                                        DSM-5 criteria for posttraumatic stress disorder
                                        Trauma exposure
                                        Trauma            Actual or threatened violent death, serious injury or accident, or sexual violence
                                        A. Exposure       Via any of the following:
                                                          1. Directly exposed to trauma
       Lasting effects of                                 2. Eyewitness (in person) to others directly exposed to trauma 
                                                          3. Learning of direct exposure to trauma of a close family member or close friend
       childhood trauma                                   4.  Repeated or extreme exposure to aversive details of traumatic event (eg, trauma 
                                                            workers viewing human remains or repeatedly exposed to details of child abuse), 
                                                            in person or via work-related electronic media
                                        Symptom groups B to E (symptoms beginning or worsening after the traumatic event)
                                        B. Intrusion      ≥1 intrusion symptoms:
                                                          1. Recurrent, involuntary, distressing trauma memories
                                                          2. Recurrent, distressing trauma-related dreams
                                                          3. Dissociative reactions/flashbacks related to trauma
                                                          4. Intense or prolonged psychological distress to trauma reminders
        Clinical Point                                    5. Marked physiological reactions to trauma reminders
                                        C. Avoidance      ≥1 avoidance symptoms:
        More than 30%                                     1.  Avoidance of or efforts to avoid distressing internal trauma reminders (memories, 
                                                            thoughts, feelings)
        of individuals                                    2.  Avoidance of or efforts to avoid distressing external trauma reminders (people, 
        who experience                                      places, activities)
                                        D.   Negative     ≥2 negative cognition/mood symptoms:
        adverse childhood                  cognition      1. Amnesia for important parts of trauma exposure
        experiences                        and mood       2. Persistent, exaggerated negative beliefs about self, others, or the world
                                                          3.  Persistent, distorted trauma-related cognitions leading to inappropriate blame  
        develop PTSD                                        of self/others
                                                          4. Persistent negative emotional state (eg, fear, horror, anger, guilt, shame)
                                                          5. Loss of interest or participation in significant activities
                                                          6. Feelings of detachment or estrangement from others
                                                          7. Persistent loss of positive emotions (eg, happiness, satisfaction, love)
                                        E. Hyperarousal   ≥2 marked alterations in trauma-related arousal and reactivity:
                                                          1.  Irritability and angry outbursts with little/no provocation (eg, verbal/physical 
                                                            aggression toward people/objects)
                                                          2. Reckless or self-destructive behavior
                                                          3. Hypervigilance
                                                          4. Exaggerated startle
                                                          5. Concentration problems
                                                          6. Sleep disturbance (eg, difficulty falling or staying asleep, restless sleep)
                                        Additional criteria
                                        F.  Duration      >1 month
                                        G.   Distress/    Clinically significant distress; social/occupational/other important functioning 
                                           impairment     impairment
                                        H.   Not          Independent of physiological effects of a substance (eg, medication, alcohol) or 
                                           attributable   another medical condition
                                           to another 
                                           disorder
                                        PTSD: posttraumatic stress disorder
                                        Source: Reference 20
                                       Diagnosing PTSD                                     Clinician-Administered PTSD Scale for 
                                                                                                   21
                                       More than 30% of individuals who expe-              DSM-5,  which is a 30-item structured 
                                                                       19 
                                       rience ACEs develop PTSD. The DSM-5                 interview that can be administered in 45 
                                       diagnostic criteria for PTSD are outlined           to 60 minutes; the PTSD Symptom Scale 
                                                   20
                                       in Table 2.  Several instruments are used           Self-Report Version, which is a 17-item, 
               Current Psychiatry      to determine the diagnosis and assess               Likert scale, self-report questionnaire; 
         24 March 2021                 the severity of PTSD. These include the             and the Structured Clinical Interview: 
               PTSD Module, which is a semi-structured              self-reliance and competence and decreases 
               interview that can take up to several hours          the generalization of anxiety to innocu-
                               21
               to administer.                                       ous triggers. PE typically consists of 9 to  
                  Other disorders.  In addition to PTSD,            12 sessions. PE alone or in combination                     MDedge.com/psychiatry
               individuals with ACEs are at high risk               with cognitive restructuring is successful  
               for other mental health issues throughout            in treating patients with PTSD, but cog-
               their lifetime. Individuals with ACE often           nitive restructuring has limited utility in 
                                                                                     25,27
               experience depressive symptoms (approxi-             young children.
               mately 40%); anxiety (approximately 30%);               Cognitive exposure can be individual or 
               anger; guilt or shame; negative self-cogni-          group therapy delivered over 3 months, 
               tion; interpersonal difficulties; rumination;        where negative self-evaluation and trau-
                                                             22
               and thoughts of self-harm and suicide.               matic memories are challenged with the 
               Epidemiological studies suggest that  goal of interrupting maladaptive behav-
                                                                                        27 
               patients who experience childhood sexual             iors and thoughts.
               abuse are more likely to develop mood,                  Stress inoculation training (SIT)  provides 
               anxiety, and substance use disorders                 psychoeducation, skills training, role-play-
                              23,24                                                                                      Clinical Point
               in adulthood.                                        ing, deep muscle relaxation, paced breath-
                                                                    ing, and thought stopping. Emphasis is on            Before starting CBT, 
                                                                    coaching skills to alleviate anxiety, fear,          ensure that your 
               Psychotherapeutic treatments                         and symptoms of depression associated 
               for PTSD                                             with trauma. In SIT, exposures to trau-              patient has the coping 
               Cognitive-behavioral therapy (CBT)  matic memories are indirect (eg, role play),                          skills to manage 
               addresses the relationship between an indi-          compared with PE, where the exposures                distress related to  
                                                                               25
               vidual’s thoughts, emotions, and behav-              are direct.                                          their ACEs
               iors. CBT can be used to treat adults and               The American Psychological Association 
               children with PTSD. Before starting CBT,             conditionally recommended several other 
               assess the patient’s current safety to ensure        forms for psychotherapy for treating patients 
                                                                               26
               that they have the coping skills to manage           with PTSD : 
               distress related to their ACEs, and address             Brief eclectic psychotherapy uses CBT and 
                                               25
               any coexisting substance use.                        psychodynamic approaches to target feel-
                                                                                                              27
                  According to the American Psychological           ings of guilt and shame in 16 sessions.
               Association, several CBT-based psycho-                  Narrative exposure therapy consists of 4 
               therapies are recommended for treating               to 10 group sessions in which individuals 
                     26
               PTSD :                                               provide detailed narration of the events; 
                  Trauma-focused–CBT  includes psycho-              the focus is on self-respect and personal 
                                                                           27
               education, trauma narrative, processing,             rights.
               exposure, and relaxation skills training.               Eye movement desensitization and repro-
               It consists of approximately 12 to 16 ses-           cessing (EMDR) is a 6- to 12-session, 8-phase 
               sions and incorporates elements of family            treatment that uses principles of accel-
               therapy.                                             erated information processing to tar-
                  Cognitive processing therapy (CPT)                get nonverbal expression of trauma 
               focuses on helping patients develop adap-            and dissociative experiences. Patients 
               tive cognitive domains about the self, the           with PTSD are suggested to have dis-
               people around them, and the world. CPT               rupted rapid eye movements. In EMDR, 
               therapists assist in information processing          patients follow rhythmic movements of 
               by accessing the traumatic memory and                the therapist’s hands or flashed light. 
                                                            25,27
               trying to eliminate emotions tied to it.             This is designed to decrease stress asso-
               CPT consists of 12 to 16 structured indi-            ciated with accessing trauma memories, 
               vidual, group, or combined sessions.                 the emotional/physiologic response from 
                  Prolonged exposure (PE) targets fear-related      the memories, and negative cognitive dis-
               emotions and works on the principles of              tortions about self, and to replace negative 
               habituation to extinguish trauma and fear            cognition distortions with positive thoughts            Current Psychiatry
                                                                               25,27                                             Vol. 20, No. 3
               response to the trigger. This increases              about self.                                                                25
                                                                                                             continued
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...The lasting effects of childhood trauma evidence based interventions can help address ptsd other symptoms in adulthood hildhood which is also called adverse child hood experiences aces have detrimen ctal on individuals as they grow and mature into may occur children age years if experience abuse or neglect violence traumatic losses more than people at least ace reported that had experienced subsequent additional a cumulative dete riorating impact brain this predisposes to mental health disorders substance use psychosocial problems efficacy current therapeutic approaches provides only partial symptom resolution for olga z getty imagessuch illness load care costs typi cally remain high across lifespan shikha verma md fapa article we discuss types protective factors medical director northern california risk influence development posttrau evolve treatment centers matic stress disorder who danville how negatively assistant professor department psychiatry behavioral prevent treat rosalind fr...

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