PSY 183 Fall 2024 Trauma-Stress-MH Law PDF

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2020, 2023, by Alan J. Fridlund, Ph.D. All Rights Reserved They May Be Downloaded for Private Use Only by Students Currently Registered in UCSB Psych 183. For-Profit Reproduc...

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2020, 2023, by Alan J. Fridlund, Ph.D. All Rights Reserved They May Be Downloaded for Private Use Only by Students Currently Registered in UCSB Psych 183. For-Profit Reproduction in Whole or In Part Without Written Permission of the Instructor Is a Violation of U.C. Regulations and the DMCA and Is Expressly Prohibited.  Notice All Course materials (class lectures and discussions, handouts, examinations, Web materials) and the intellectual content of the Course itself are protected by United States Federal Copyright Law, and the California Civil Code. UC Policy 102.23 expressly prohibits students (and all other persons) from recording lectures or discussions and from distributing or selling lectures notes and all other course materials without the prior written permission of the Instructor (See http://policy.ucop.edu/doc/2710530/PACAOS-100). Students are permitted to make notes solely for their own private educational use. Exceptions to accommodate students with disabilities may be granted with appropriate documentation. To be clear, in this class students are forbidden from completing study guides and selling them to any person or organization. The text has been approved by UC General Counsel. Traumatic and Stressor-Related Disorders  Kinds of Stress or Trauma Exposure That Can Precipitate Acute and Post-Traumatic Stress Disorders Exposure to actual or threatened death, serious injury, or sexual violence (in children, inappropriate sexual experiences even without violence or injury), in one (or more) of the following ways: - Directly experiencing the traumatic event(s). - Witnessing, in person, the event(s) as it occurred to others. - Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. - Experiencing repeated or extreme exposure to aversive details of the traumatic event(s), e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse. This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related  Reactions to Extreme Trauma ⚫ Intrusive recollections (daytime flashbacks, nightmares, illusions), and acute distress upon cues suggestive of the trauma ⚫ Dissociative symptoms (“psychic numbing”): their presence in stress disorders is associated with greater impairment – emotional detachment – being in a “daze” – dropping out of usual activities, e.g., “going off the grid” – avoidance of topics related to trauma – forgetting or “fogginess” re: key aspects of trauma (“Dissociative amnesia”, seen frequently in combat veterans as part of “shell shock”) – time distortion (usually “slow-motion”) – feeling that the current setting is “dreamlike,” not real, and not registering events in surroundings (derealization) – feeling detached from one’s body (depersonalization) ⚫ Chronic hyperarousal: exaggerated startle, insomnia, hypervigilance, motor restlessness (agitation) ⚫ Irritability, unprovoked angry outbursts, and aggressiveness (esp., males) ⚫ Survival guilt / shame – belief that one doesn’t deserve to live when others have died (guilt), and that one has been marginalized (shame). ⚫ Reckless, impulsive behaviors (may relate to survival guilt/shame) *Dissociative Disorders will not be covered in Psych 183 Major Trauma and Stressor-Related Disorders (DSM-5-TR) ⚫ Acute stress disorder (Disability > 2 days and < 1 month) – Occurs in 20% of cases that do not involve interpersonal assault (e.g., accidents), and 20-50% of cases following interpersonal assault – Involves extreme levels of anxiety that interfere with sleep, energy levels, ability to concentrate, and leads to general withdrawal, work absenteeism, diminished self-care and ability to parent. ⚫ Post-traumatic stress disorder (PTSD) (Disability >= 1 month) – PTSD – from a traumatic episode or series of episodes – Prevalences depend on both trauma and pre-existing risk factors. – Complex PTSD (CPTSD)* – from prolonged trauma ⚫ About 10% of people with PTSD show Delayed Expression, when signs/symptoms are insufficient in acute phase for a diagnosis, but increase over succeeding months to the point that they are diagnosable as PTSD. *Research diagnosis, not in DSM-5-TR  Case Study: Acute Stress Disorder A 10-year-old girl child, studying in Grade III, Hindu by religion, Chhetri by caste, and hailing from Sindhupalchowk was brought to paediatric emergency at Tribhuvan University Teaching Hospital by her elder sister with a history of weakness of right side of the body, decreased food and fluid intake, loss of speech output, disturbed sleep and two episodes of urinary incontinence for five days following survival from a major earthquake that took place on 12th Baisakh, 2072.* She was buried in a demolished house for three and half hours on that day. She had distressing dreams at night related to the earthquake and showed intense fear to earthquake related cues. She appeared sad and fearful and was hypervigilant. She showed startling response at times and had difficulty in concentration at work. She was irritable for the first few days after admission and showed anger outbursts. However, she had difficulty in recalling the traumatic event. Pre-morbid temperament revealed a playful, interactive, obedient, extrovert and studious personality with predominant mood being euthymic. - Gautum et al. (2017). J. Katmandu Medical College, 5, 98-100. * 12th Baisakh 2072 in the Nepalese calendar corresponds to the Gregorian date of April 25, 2015.  Case Study: Post-Traumatic Stress Disorder Victor is a 27-year-old man who came for help at the urging of his fiancée. He was an infantryman with a local Marine Reserve unit who was honorably discharged in 2014 after serving two tours of duty in Iraq. His fiancé has told him he has “not been the same” since his second tour of duty and it is impacting their relationship. Although he offers few details, upon questioning he reports that he has significant difficulty sleeping, that he “sleeps with one eye open” and, on the occasions when he falls into a deeper sleep, he has nightmares. He endorses experiencing several traumatic events during his second tour, but is unwilling to provide specific details – he says that he has never spoken with anyone about them and he is not sure he ever will. He spends much of his time alone because he feels irritable and doesn’t want to snap at people. He reports that he finds it difficult to perform his duties as a security guard because it is boring and gives him too much time to think. At the same time, he is easily startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty and at home. He describes having intrusive memories about his traumatic experiences on a daily basis but he declines to share any details. He also avoids seeing friends from his Reserve unit because seeing them reminds him of experiences that he does not want to remember.  Acute and :Post-Traumatic Stress Disorders U.S. Airways Flight 1549 (1/15/09) “The Miracle on the Hudson” * * Captain “Sully” Sullenberger was forced to ditch his disabled plane on the Hudson River in NYC, and saved the lives of all 155 crew and passengers. Aviation experts believed his water landing was nearly impossible.  Acute Stress Disorder: U.S. Airways Flight 1549 (1/15/09) “I was terrified for my soul … you knew you were going to crash. I was two seconds from drowning. The first few nights in the hospital I had water dreams about drowning in the galley of the plane… My insides have not stopped shaking.” - Flight Attendant Doreen Welsh from People (2/23/09)  “Each flight is getting more stressful” ** Post-Traumatic Stress “It starts with an Disorder: adrenaline rush … U.S. Airways Flight 1549 your heart skips a (1/15/09) beat. Then you start thinking, ‘Was that a normal sound or was it another bird going through the engine?’ I hope it will pass.” - Passenger Joe Hart, who flew over 11 times in the months following the crash from People (2/23/09) ** “Incubation” or progression of acute symptoms in PTSD 9/11/2001  Post-Traumatic Stress Disorder ⚫ Prevalence: – 2-3 % point prevalence in the general U.S. population, lifetime prevalence is ~7%, and ~4% worldwide. – F:M ~ 2:1, may partly reflect greater vulnerability to interpersonal violence. – among U.S. adolescents, lifetime prevalence is 5-8%. ⚫ ~ 90% of ASD sufferers go on to have PTSD, with signs/symptoms occurring ~3 mo after the trauma. ⚫ 10% of those with PTSD show delayed expression (PTSD w/o diagnosable ASD). ⚫ Males and females show similar sign/symptom patterns in PTSD, except that: – females are likelier to show numbing and anxious avoidance, and suffer from PTSD longer than men. – males are likelier to show irritability and ETOH abuse. – children may show developmental regression (loss of language, toileting issues), aggression, social isolation, distressing dreams ⚫ Any PTSD recovery is hampered by frequent development of avoidant lifestyle (of people and/or “triggers”), Major Depression and Generalized Anxiety Disorder, and ETOH/Drug Abuse and Dependence. ⚫ In non-Western cultures, avoidance behavior may be less common, but somatic symptoms (e.g., dizziness, SOB, heat sensations) may predominate.  Common Precipitants of Trauma and Stressor-Related Disorders ⚫ Sexual violence (attempted or completed rape, and sexual assault) – >300,000 attempted or completed rapes per year in U.S., ~10:1 F:M – Females 16-19 are most common demographic for sexual violence – College females 18-24 have 3X the risk of females in general, non-college females 18-24 have 4X the risk – Females in non-combatant military service ⚫ Among females, 55% serving and 38% of veterans report sexual harassment. ⚫ 23% of females serving report a history of sexual assault. ⚫ Military combat – PTSD is developed by 18% of combat veterans and 70% of P.O.W.’s, and typically lasts 1-2 years, but among those veterans, it is lifelong for 30% and 78% of P.O.W.’s. – 80+% are resilient to PTSD regardless of combat exposure. – Those who entered the service with prior PTSD signs/symptoms and who did not see direct combat found their service psychologically beneficial with reduced existing PTSD signs/symptoms. Those who had combat exposure developed worse PTSD signs/symptoms. ⚫ Physical / emotional abuse (childhood sexual/physical abuse, domestic violence, workplace abuse) ⚫ Human calamities – Deliberate: bombings, torture, death camps, terrorism, being a crime victim or hostage – Accidental: motor vehicle accidents, plane crashes, gun accidents, workplace accidents ⚫ Physical trauma (surgery, disease, disfigurement, head trauma) ⚫ Climatic calamities: floods, tsunamis, tornados, hurricanes, earthquakes, fires  Risk Factors for Developing Trauma and Stressor-Related Disorders after Trauma ⚫ Severity and chronicity of trauma. and subsequent adverse life events ⚫ Family history and/or current depression or anxiety disorders ⚫ Family history of PTSD - studies show specific heritability for PTSD. ⚫ Racial or ethnic minority status (may reflect discrimination, past adversity, availability of good treatment, lack of social support) – associated with greater risk and longer course. ⚫ Poor coping habits (smoking, drinking and other preexisting drug use) ⚫ Intergenerational trauma – cultures with horrific histories often teach the young, through words and deeds, “Don’t trust others, don’t trust the world.” ⚫ Animal studies suggest that the effects of trauma may persist to the 3rd generation, suggesting that epigenetics may also contribute to intergenerational trauma. ⚫ Poor social support (esp. combat vets, but also rape & assault victims)  Complex PTSD (CPTSD)* ⚫ Special case of PTSD reserved for repeated or continuous trauma over months or years. ⚫ Symptoms can be more extreme and longer-lasting than with “simple” PTSD. ⚫ Common kinds of CPTSD trauma: – being a victim of neglect or emotional, physical and/or sexual abuse – growing up in a family with domestic abuse – being a POW or living in a war zone – being a victim of human trafficking – having a series of illnesses, medical procedures, surgeries ⚫ Associated w/ usual PTSD signs and symptoms but also: – changes in worldview, religion, philosophy, basic trust, and views of relationships – preoccupation with traumatic history and revenge fantasies toward abusers ⚫ Controversial diagnosis: the debate is mostly over whether CPTSD is simply severe PTSD. *Research diagnosis, not in DSM-5-TR  Psychotherapy for PTSD ⚫ 1st-line psychotherapeutic treatment: exposure therapy relying on visualization of trauma-related cues, combined with relaxation, to extinguish conditioned fear responses. ⚫ Cognitive-Behavior Therapy (CBT)/Cognitive Processing Therapy(CPT); focus is on “thought neutralization” and finding new ways to interpret and live with trauma. ⚫ EMDR - Eye movement desensitization / reprocessing; based on dubious neurological model, with no evidence for special effectiveness compared to generic supportive therapypolyvagal therapy ⚫ Polyvagal therapy – Like EMDR, based on a dubious neurological model, but focuses on bodily awareness and anxiety reduction. ⚫ Group therapy / self-help (rap) groups: for estrangement, catharsis and support ⚫ Stress management training (structuring life-space, to-do lists, setting priorities) ⚫ For CPTSD sufferers, realign or reframe relationship with abuser(s) ⚫ Finding meaning in tragedy (“sublimation”): – “Mothers Against Driving Drunk” (MADD) was founded by Candy Lightner, whose 13-yr-old daughter was killed in 1980 by a drunk hit-and-run driver, in Fair Oaks, CA. – “Amber Alerts” for child abductions, named for Amber Hagerman, a 10-yr-old girl abducted and murdered in 1996 while riding her bike in Arlington, TX. Amber’s father started the alerts along with the father of Polly Klaas, who was abducted from her bedroom and murdered in Petaluma, CA, in 1993.  Group Management for Acute Stress: Critical Incident Stress Debriefing ⚫ Fact phase: Ask victims to tell their stories. ⚫ Reaction phase: Ask victims to report their thoughts and feelings about the incident. ⚫ Symptom phase: Solicit symptomatology and suggest coping strategies. ⚫ Teaching phase: Educate victim regarding traumas and typical reactions to trauma. ⚫ Reentry phase: Wrap-up, answer Q’s, provide referrals, develop plan of action. Note: Little evidence that such debriefings have much effect in reducing subsequent sign/symptom development.  Medication Treatment of ASD and PTSD ⚫ Symptomatic care: – Anxiolytics for short-term management of anxiety, panic attacks – Antidepressants (mainly SSRI’s) for chronic depression, anxiety, irritability – Antipsychotics (e.g., Abilify, Risperdal) for any paranoia, social estrangement, psychotic dissociative phenomena, etc. – Sleep medications (e.g., Lunesta, Ambien, Remeron, Trazodone) for insomnia – Cannabinoids in individual cases for anxiety, but may worsen PTSD signs/symptoms and complicate efforts to reduce avoidance behavior. ⚫ Antihypertensive medication prazosin (MinipressTM) for anxiety spikes, flashbacks, nightmares; probably works by “steadying” Sympathetic N.S.; works best for people who are already hypertensive. ⚫ Experimental: – post-stressor propanolol (Inderal), an anti-hypertensive drug that blocks adrenalin, reduces memory consolidation after stress, and seems to reduce the intensity of subsequent PTSD symptoms, but unproven in long-term clinical studies. What is the drawback of such memory-dulling post-stressor treatments? – Psychedelic administration - part of “substance-assisted psychotherapy” – all these compounds are promising, but data on effectiveness and safety are inadequate: ⚫ MDMA (“ecstasy”) ⚫ Psilocybin (“mushrooms”) ⚫ LSD (“acid”) ⚫ Ketamine (“special K”) ⚫ DMT (“Dimitri”) Mental Health Law and Regulations NOTE: All California Mental Health Laws are listed and described in the Mental Health Law (2019) publication by the California Hospital Association, available at: www.calhospital.org > Publications > Manuals Confidentiality: Mental health Information cannot be released without patient consent except in specific circumstances: ⚫ DUTY TO WARN/PROTECT: A patient (or his/her immediate family member) communicates a serious threat of physical violence against a reasonably identifiable victim or victims (Note: past crimes are not reportable). ⚫ The psychologist has reasonable cause to believe a patient is a danger to him/herself and disclosure of information is necessary to avert the danger. ⚫ Within the psychologist’s professional role, he/she comes to suspect reasonably that an under-18 child, or an elder or dependent adult, is being abused or neglected. ⚫ A patient has agreed within a managed-care environment (e.g., Kaiser Permanente) to release records routinely to the HMO’s electronic medical records (EMR) database. ⚫ A court orders the psychologist to release records or provide testimony needed as evidence in a legal proceeding. ⚫ If, under Section 215 of the Patriot Act of 2001, an order from a Foreign Intelligence Surveillance Act (FISA) Court demands all health practitioners to provide the FBI with certain patient information upon request, with that request prohibited from being disclosed to either the patient or anyone else.  Involuntary Commitment, i.e., “5150’s” etc. All are covered by California’s Lanterman–Petris–Short (LPS) Act (1967) When a patient’s behavior warrants hospitalization, voluntary hospitalization is always preferred. Involuntary commitment is legally permitted only when: – (1) the patient poses an imminent (“right now”) danger to self or others, or is gravely disabled. – (2) the danger or grave disability is the result of a mental disorder or chronic alcoholism. – (3) the patient has refused or is unable to comply with a recommendation to enter a psychiatric facility voluntarily.  Two Types of Involuntary Commitment ⚫ 5150 Hold: 72-hour treatment and evaluation, instituted by county- designated “5150-certifed” personnel: police officer, registered nurse, medical doctor, in a facility or on a mobile mental health crisis team. Patient is discharged from 5150 hold early if treating psychiatrist finds no grounds for continuance. Patient is discharged automatically after 72 hours if not approved for additional hold. ⚫ 5250 Hold: 14-day hold added after 72-hour 5150 hold to allow intensive treatment related to a mental disorder or alcoholism when: – the patient is a danger to self or others, or is gravely disabled, and – treatment is required but the patient has refused. This hold is certified by two professionals, patient’s representative is notified, and hold is subject to prompt judicial review. Additional 14- day “post-certification holds” can be amended for a total period not to exceed 180 days if found necessary. Any failure of certification results in prompt discharge of patient. A Crisis of Placement  Involuntary Long-Term Custodial Care: “Conservatorship” The patient who is “gravely disabled as a result of a mental disorder or impairment by chronic alcoholism” may be placed in the hands of a conservator temporarily (30 days) or long-term (“LPS Conservatorship,” renewable indefinitely at 1-year periods). Britney Spears On February 1, 2008, American entertainer Britney The conservator is responsible to the Spears was involuntarily placed under appointing court for a comprehensive living a conservatorship by Judge Reva Goetz, with her father, and treatment plan for patient. Licensed James "Jamie" Spears, and attorney Andrew M. Wallet, conservators can manage gravely disabled as conservators. The conservatorship lasted until people on behalf of family members. November 2021.  Assisted Outpatient Treatment (AOT) “Laura’s Law” ⚫ Allows court-ordered outpatient treatment (“assisted outpatient treatment,” or “outpatient commitment”) for people with mental disorders – controversial due to civil rights implications. ⚫ Used as a “bridge” when patients are discharged from inpatient facilities, still in crisis, yet cannot yet maintain his or her own treatment. ⚫ Assignment to AOT is made by court order. Court hearings require that patient have an attorney or public defender. Assignments last 180 days and may be renewed following re- evaluation of the patient. ⚫ Most AOT recipients have severe Bipolar Disorder or Schizophrenia, half have ongoing substance abuse and have not complied with their medication, 97% have been hospitalized. ⚫ Research shows that AOT greatly reduces arrests, incarcerations and hospitalizations, homelessness and victimization, and saves money. Mental Health Law Touches UCSB  CA Law AB 1014 – Temporary Gun Seizure (Signed 9-1-2014)* Authorizes a court to issue a gun violence restraining order if a law enforcement officer asserts, and a judge finds, that there are reasonable grounds to believe that the person, by owning or having a firearm and/or ammunition, may cause injury to himself or designated others. Any weapons/ammo must be turned in to the police, sold, or placed in custody of a licensed gun dealer. The restraining order is issued without prior notice to the named person and without the benefit of a court hearing where the named person is present to defend himself before the order is issued and their firearms are seized. A hearing is held within 21 days following issuance of the gun violence restraining order. * Passed 4 months after May, 2014, Elliott Rodger IV Massacre End