UOW PSYC251 Lecture 4 PDF

UOW PSYC251 Lecture 4 Mala Khare  Today’s agenda Trauma Addictive behaviours Consultation Childhood Trauma  Trauma When a stressor overwhelms one’s own coping resources – Threat of death/serious injury to one’s self or someone...

UOW PSYC251 Lecture 4 Mala Khare  Today’s agenda Trauma Addictive behaviours Consultation Childhood Trauma  Trauma When a stressor overwhelms one’s own coping resources – Threat of death/serious injury to one’s self or someone else – Threat to one’s physical, sexual, psychological integrity or someone else’s Person’s response involved intense fear, helplessness, or horror.  Childhood Trauma refers to An experience of an event by a child that is emotionally painful/ distressful that overwhelms their ability to cope – Repeated threat (uncontrollable danger) or neglect/ deprivation (omission of care) – Exceeds child’s coping resources leading to prolonged stress It often results in lasing mental and physical effects. Childhood trauma: 2 Types of Trauma Single incident trauma – One-off event – E.g.: witnessing a car accident or being mugged at gun-point Complex trauma – Threat happens repeatedly, often involves an attachment figure as a perpetrator. – Includes abuse & neglect, DV & the experience of living in a violent community.  DSMV A. Exposure to actual or threatened death, serious injury or sexual violence (direct experience, witnessing or hearing about in close friend or family member; repeated or extreme exposure to traumatic details) B. 1+ intrusion symptoms (intrusive memories, dreams, dissociation or flashbacks, ++distress and/or physiological reactions) C. Persistent avoidance D. Altered cognitions or mood (inability to remember aspects of trauma, persistent negative self-beliefs or beliefs about cause/cons of event, detachment, mood, loss of pleasure) E. Arousal & reactivity (sleep, hypervigilance, irritability & anger) F. >1 month G. Clinical significant distress or impairment H. Not due to effects of substance  Complex Trauma Developmental Trauma Complex trauma is associated with the failure of those who should be protecting & nurturing the child. It has profound & far-reaching effects on nearly every aspect of the child’s life. Injuries acquired through stress dysregulation because of unmet infant attachment needs may be described as developmental trauma Unregulated stress in early years can damage developing brain architecture – Children with unmet attachment needs often cannot regulate stress  Complex Trauma Developmental Trauma When-Multiple, chronic & prolonged Often of interpersonal nature- early life onset Negative changes in a child’s neurological, biological, & emotional development Effects are cumulative – social, emotional, cognitive impairment – higher risks for medical conditions (heart disease, severe obesity) – higher risk for substance abuse, depression – Inability to form healthy attachments  Symptoms of Traumatic Stress Dissociation--Sensory awareness is lost – protective reaction to the pain of overwhelming stress – avoidance, compliance (appease), dissociation, fainting Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.  Many traumatized children, and adults who were traumatized as children, have noted that when they are under stress they can make themselves ‘disappear.' That is, they can watch what is going on from a distance while having the sense that what is occurring is not really not happening to them, but to someone else. van der Kolk, 1996 Symptoms of Traumatic Stress Hyperarousal-Stress remains in awareness – ('fight or flight'), i.e., vigilance, resistance (freeze), defiance, aggression The younger the individual, the more likely he/she is to use dissociative adaptations rather than hyper-arousal responses (Perry et al., 1995). Symptoms of Traumatic Stress Attachment challenges – Pull/Push-come close, now go away; afraid of getting close – Parents personalize children’s negative behavior –further challenges attachment Symptoms of Traumatic Stress Behavioral Control – Poor impulse control – Self-destructive behavior/aggression – Sleep disturbances/eating disorders – Fear driven responses High risk behaviors – Control issues- children feel so out of control they try to control everything in whatever way they can  Symptoms of Traumatic Stress Biology: problems with movement & sensation, including hypersensitivity to physical contact & insensitivity to pain. Exhibit unexplained physical symptoms & increased medical problems (difficulty sleeping, eating, headaches, stomach aches; lowered immune system; disrupted toilet training / wetting) Hypervigilance (chronic physical arousal)  Symptoms of Traumatic Stress Mood regulation. Children exposed to trauma can have difficulty regulating their emotions, as well as difficulty knowing & describing their feelings & internal states. Pervasive feelings- fear, anxiety, depression, self-harm, addictions, oppositional behaviors, Feelings of powerlessness & helplessness  Symptoms of Traumatic Stress Cognition. Traumatized children can have problems focusing/concentering & completing tasks, or planning for & anticipating future events. Some exhibit learning difficulties & problems with language development  Symptoms of Traumatic Stress Self-concept: Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, & guilt. Internalized beliefs- I’m a bad kid, I can’t trust adults, people who say they love you, hurt &/or leave you, the world is not a safe place to be Core issues-grief, loss, rejection, attachment, control, guilt, identity  Symptoms of Traumatic Stress Memory – Lack cognitive memory of events – Memory of trauma stored in the senses, the body – State dependent memory Single traumatic events are most often forgotten by young children since as the brain develops it disposes of the synaptic connections (links between brain cells or neurons) that "remember" them. Repeated events build up more of these connections and thus stay in the mind--though not necessarily in the recoverable memory. Myth: If a child has no cognitive memory of a loss, then they don’t grieve & have no long lasting effects. – Unremembered but Unforgotten (Winnicott)  Childhood trauma & PTSD Children who have experienced chronic or complex trauma frequently are diagnosed with PTSD. According to the APA, PTSD may be diagnosed in children who have: – Experienced, witnessed, or been confronted with one or more events that involved real or threatened death or serious injury to the physical integrity of themselves or others – Responded to these events with intense fear, helplessness, or horror, which may be expressed as disorganized or agitated behavior  Childhood trauma & PTSD Key symptoms of PTSD – Re-experiencing the traumatic event (e.g. nightmares, intrusive memories) – Intense psychological or physiological reactions to internal or external cues that symbolize or resemble some aspect of the original trauma – Avoidance of thoughts, feelings, places & people associated with the trauma – Emotional numbing (e.g. detachment, estrangement, loss of interest in activities) – Increased arousal (e.g. heightened startle response, sleep disorders, irritability)  How Traumatized Children are Typically Diagnosed Other common diagnoses/misdiagnoses for children exposed to trauma include: – Reactive Attachment Disorder – Separation anxiety disorder – ADHD – Oppositional Defiant Disorder – Bipolar Disorder – Conduct Disorder These diagnoses generally do not capture the full extent of the developmental impact of trauma. Many children with these diagnoses have a complex trauma history.  Trauma impairs and alters brain function Traumatic Event Prolonged Alarm Reaction Altered Neural Systems Hierarchy of Brain Development Neocortex Limbic Diencephalon Brainstem Brain development “THINKING BRAIN” The brain grows in “EMOTIONAL sequence. BRAIN” “Reacting Brain” develops very early. “Thinking Brain” “REACTING BRAIN” does not develop fully until much SIGNALS TO later. BODY  “Reacting Brain” & the “Thinking Brain” “Reacting Brain” is responsible for a unconscious things, like breathing, & for rapid responses to danger. “Thinking Brain” is responsible for such things as reasoning, planning & impulse control. – In neurological terms, the thinking brain is known as the neocortex &, unlike the reacting brain, the thinking brain develops much later.  The “Emotional Brain” The development of the “Emotional Brain” begins early but the ability to use the “Thinking Brain” to control emotions as they are felt & to express them appropriately develops later. Children learn how to express, recognise & regulate different emotional states from the adults around them & from the way they are cared for.  Fight/flight/freeze reactions The fight/flight response is a 40,000- year-old model, its alarm reaction is designed for short-term use to deal with physical threats in which the emergency resolves very quickly in a few seconds or minutes; either we kill the wild animal or it kills us!  TH R EAT FREEZE FIGHT FLIGHT  The Alarm System (Over stimulation) Problems arise when the alarm system is over sensitised or over used, as occurs with repeated trauma where the alarm system is continually triggered. – The alarm response can be triggered by memory of a traumatic event but also by relational and emotional triggers.  The “Fight” Response Some older children may engage in severe temper tantrums. – These need to be distinguished from normal willful tantrums, which are conscious & purposeful. The “Flight” Response Flight in older children may take the form of absconding – Dissociation is a kind of psychological escape & is common in babies & very young children who cannot run away. “Freeze” Response in Traumatised Children Use freezing response (Brief immobilization of the body & mind) more often & the response can be prolonged – Can revert to the freezing response when anxious or stressed & may not be conscious of this Freezing can be misinterpreted as ignoring requests or refusal to comply & result in inappropriate management of the problem which may further increase the child’s anxiety  Jason has been abused at home and is now living with foster carers. He overhears his foster carers arguing. Because of his previous experience he is afraid he will be attacked. This sends his body into survival mode. In survival mode, Jason can either attack first to get the upper hand (fight), runaway to a safer place (flight) or stay as quiet and as still as possible so he isn’t noticed (freeze) Impact of complex trauma on stress response systems and brain development Short term stress response system (SEM) Release of Adrenaline Inappropriate Freeze/Flight/Fight responses Long term stress response system (HPA: hypothalamic–pituitary–adrenal ) Release of Glucocorticoid hormones – Too much cortisol suppresses immunity, increasing risk of infection – Inflammatory response persists after it is no longer needed  Impact of complex trauma on stress response systems and brain development – Amygdala hypertrophy: – Trauma appears to increase activity in the amygdala. Alarm turned on – not able to take input from other areas to quiet alarm – Hippocampus atrophy Difficulty with learning and memory – Frontal cortex Shut down of executive function – impulse control, working memory and cognitive flexibility Impact of complex trauma on stress response systems and brain development Affects tiredness/energy across the day: Lack of engagement in school Brain regions with protracted development are vulnerable Brain regions with high density glucocorticoid receptors are vulnerable At 3-5 years, hippocampus is vulnerable: Cognitive difficulties  Attachment & Recovery Adults when validate & empathise with the baby are providing patterns for: – Awareness of feelings – Empathy – Pleasure in social interaction These patterns change the structure of the developing brain People who lack these experiences will always be thinking & feeling with a different brain  Recovery from trauma 1. requires increased safety – ensuring that a person is both physically & emotionally safe from harm. 2. Move to increased reflection – traumatic experiences are converted to memories through language 3. Move to increased functioning – involving re-engagement & reconnection with the world through behaviours & relationships.  Trauma and Treatment Often referred to psychologists for treatment in a 8-12 session model. Treating attachment problems & treating childhood trauma both require an understanding of their interrelatedness However, a therapeutic relationship may be very challenging for such a client. Therefore, facilitating the caregiver to understand trauma & to provide a safe, calm & attentive relationship with the child is often a far more efficient way to recovery.  van der Kolk’ 05, "a highly significant relationship between adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity and sexually transmitted diseases. In addition, the more adverse childhood experiences reported, the more likely a person was to develop heart disease, cancer, stroke, diabetes, skeletal fractures and liver disease." "People with childhood histories of trauma, abuse and neglect make up almost the entire criminal justice population in the US." § Addictive Behaviours  Addictive behavior that which becomes the major focus of a person's life resulting in a physical, mental, &/or social withdrawal from their normal day to day obligations – Something that is unhelpful, but one continues to do Substance addictions (drugs, alcohol…) Behaviour addictions (gambling, sexual activity….) Types of addictive behaviors Alcohol and substance abuse Sex addiction Gambling Internet/Video games Overeating Shopping Exercise  American Psychiatric Association Substance Abuse: when substance use leads to clinically significant impairment or distress (e.g. Losing a job, failure to abstain during pregnancy, recurrent consequent legal problems) Substance Dependence refers to the physical aspects of addiction- need for more  Why addiction? Initially attraction to a substance/activity § Pleasurable Any activity or substance (Drugs, alcohol, smoking) that has the potential to produce positive mood change has the potential to become addictive § Tranquilizing feelings with substance, activity Alleviate the emotional pain by taking the focus away from the source to a different activity  Why addiction? § Peer pressure especially for the adolescents § Social acceptance § Some addictions are better socially accepted & evoke less negative reaction – Workaholism, food as compared to substance abuse Psychological dependence vs. addiction  Signs of Addiction – Obsession: excessive preoccupation with the behavior & overwhelming need to perform it – Loss of control: inability to reliably predict whether any isolated occurrence of the behavior will be healthy or damaging – Negative consequences: such as physical damage, legal trouble, financial problems, academic failure, & family dissolution – Denial: inability to perceive that the behavior is self-destructive.  The Addictive Process Nurturing through avoidance – seeks the illusion of relief to avoid unpleasant feelings or situations The physiology of addiction – Neurotransmitters exert their influence at specific receptor sites on nerve cells. Drug use & chronic stress can alter these receptor sites & cause the production & breakdown of neurotransmitters – Tolerance larger doses needed to obtain the desired effects – Withdrawal symptoms Cycle of Psychological Addiction  Model of Addiction Bio-psycho-social model addiction is caused by a variety of factors operating together. Biological or disease influences-genes affecting the activity of the neurotransmitters serotonins & GABA are likely involved in the risk for alcoholism Environmental influences-Cultural expectations, attitudes, & messaging, Social learning theory Psychological factors  Risk Factors for Addiction Copyright © 2010 Pearson Education, Inc.  § The Substance use Disorders Slides with Arial format are from from Dr Pete Kelly  Drugs and Their Effects Drug: chemical substance that affects the way one feels & function Some drugs have a positive effect- they help the body heal Other drugs have a negative effect- they distort reality, etc.  Drugs and Their Effects All drugs (including those prescribed by a doctor) have some side-effects, often they interact with each other Prescription Drug Abuse Leads to very similar behaviour as for other addictions e.g., increased efforts to get prescriptions, withdrawal from other interests & activities; & even increased use of alcohol to supplement the effects of the pills.  Substance addiction More common in – Men – Younger people-peer group pressure Marijuana - most commonly used illegal drug. Other drugs include stimulants such as cocaine, amphetamines, heroin, hallucinogens, sedatives & inhalants. heroin & cocaine, more quickly result in physical addiction than do others – but all drugs can be abused  Cannabis Other names Grass, pot, dope, Mary Jane, hooch, weed, cones, smoke, hydro & joints Trends Most widely used illicit drug in Australia. – 34% of 14-19 yr olds ever used – 59% of 20-29 yr olds ever used – 32% of individuals over 14 years of age have ever used 2004 National Drug Strategy Household Survey  What is Cannabis Types Method of Use – Marijuana – Smoked Dried flowers & Hand rolled leaves from plant cigarette - eg. – Hashish Joint Resin or secreted Bong gum from plant – Eaten – Hash Oil May be added to Thick oil obtained food e.g. hash from hashish cookies  Effects of Cannabis Short Term Long Term – Feeling of – Increased risk of wellbeing respiratory disease – Drowsiness – Decreased – Increased memory and appetite learning ability – Loss of co- – Decrease ordination motivation – Anxiety & – Clear links to paranoia psychosis  Amphetamines Other Names Speed, go-ee, whiz, uppers, buzz, crystal meth, gas, base, ice & shabu Trends 8% of Secondary school students report using 9% of individuals over 14 years of age have ever used 22% of 20 - 29 year olds have tried Speed 2004 National Drug Strategy Household Survey  What are Amphetamines? Types Method of Use – Powder – Snort Can vary in – Swallow colour & quality – Inject eg. Speed – Smoke – Crystallised More potent form Ice or Shabu  Effects of Amphetamines Short Term Long Term – Euphoria & well – Sleep problems being – Ex. Mood swings – Hyperactivity – Paranoia – Decreased – Anxiety appetite – Seizures – Dry mouth – ‘Speed psychosis’ – increase BP and HR Note: Amphetamines can vary in quality, consistency & make up  Ecstasy Other Names E, eccy, XTC, pills, eggs & doves Trends Users tend to be young, most being aged in their late teens / early 20’s Users are relatively educated, most completed High School and substantial proportion attending Uni On average regular users use Ecstasy between weekly and fortnightly National Drug & Alcohol Research Centre (2002)  What is Ecstasy What is ecstasy? – Combination of Substances similar to MDMA – Poor quality control - may include: Methamphetamine Hallucinogens Caffeine or Paracetamol Often no MDMA MDMA (methylenedioxy methylamphetamine  Effects of Ecstasy Short Term Long Term – Euphoria – Neurotoxicity – Feelings of closeness – Memory and with others cognitive problems – Lack inhibitions – Depression – Increased body temp. – Teeth grinding – Dry mouth – Inability to sleep  What is Heroin? Opioid made from the Method of Use opium poppy – Snorted Mixed with cutting agents – Chasing the dragon (Cutting' refers to the means Heat & inhale fumes by which illicit drugs are – Injected (users follow a diluted) such as: classic progression from – glucose & sniffing (similar to the oral Paracetamol route) to “skin popping” (subcutaneous route) to “mainlining” (intravenous route) Mainlining Skin popping Intramuscularly  Effects of Heroin Short Term Long Term – Euphoria & well – Constipation being – Lowered sex drive – Nausea & vomiting – Social & financial – Dilation of pupils – Tolerance – Drowsiness – Withdrawal – Slurred speech – Overdose – Relief of pain  Street Drugs Summary w Quality, quantity & consistency may change w Drug names reported by clients may not correspond to the drug used w Poly drug use is common (i.e. using more than one drug) w Drug use is often accompanied by a comorbid mental health disorder  Substance use disorder (DSM-5) 2 of the 11 over a 12 month period (1) Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home. (2) Recurrent substance use in situations in which it is physically hazardous. (3) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. (4) Tolerance, as defined by either of the following: (a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect. (b) Markedly diminished effect with continued use of the same amount of the substance. (5) Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for the substance (refer to Criteria A or B of the criteria sets for Withdrawal from specific substances). (b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.  (6) The substance is often taken in larger amounts or over a longer period than was intended. (7) There is a persistent desire or unsuccessful efforts to cut down or control substance use. (8) A great deal of time is spent in activities necessary to obtain the substance (such as visiting multiple doctors or driving long distances), use the substance (such as chain smoking) or recover from its effects. (9) Important social, occupational, or recreational activities are given up or reduced because of substance use. (10) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. (11) Craving or a strong desire or urge to use a specific substance Alcohol addiction Alcohol consumption is high in general population (higher in young) Besides health related illnesses, it impacts judgment that leads to higher number of vehicle accidents & aggressive episodes  Alcohol addiction Alcohol has been falsely thought of as a stimulant because its initial effects on some people include feelings of euphoria & lowered inhibitions. BUT it s a depressant because it later causes sedation & drowsiness. – In high concentrations, alcohol can induce unconsciousness, coma, & even death.  Biology of Dependence Dependence is a brain disorder triggered by frequent use Many drugs cause release of dopamine (neurotransmitter) Can reach a point that natural [dopamine] is not adequate to cause satisfaction  Causes Medical model: It is a disease characterised by brain impairment Addictive substances act on the brains reward systems Genetics- more common in some families & likely involves the effects of many genes Adoption & twin studies also support genetic factors Social Learning Model : Family of origin- learnt behavior (Modeling)  Causes: maladaptive use of substance reflects a rational choice Personality -thrill seeker, impulsive & resistant to social norms Social environment – Peer pressure – Lack of attachment may increase risk of addiction Psychological problems – Coping response to Anxiety, depression & loneliness, attention deficit disorder & PTSD  Why do some people become addicted, while others do not? Nothing can predict whether or not a person will become addicted to drugs. Risk factors are: Biology. Genes, gender, ethnicity, presence of other mental disorders may increase risk for drug abuse & addiction. Environment. Peer pressure, physical & sexual abuse, stress, & family relationships can influence the course of drug abuse & addiction in a person's life. Development. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it is to progress to more serious abuse.  Addiction impacts not just the addict but the whole family – Family members may become Enablers – knowingly or unknowingly protect addicts from the natural consequences of their actions – Rarely conscious & generally unintentional  Treatment 1. Assessment 2. Consider motivation 3. Targeted intervention 4. Harm minimization  Assessment: Brief Screen w Do you sometimes think you shouldn’t drink, or maybe drink less? w Do you feel angry or upset when other people get on your back about drinking, or tell you to cut down? w Do you ever feel shame or guilt about drinking? w Do you sometimes take a drink early in the morning for headache or because you feel no good, a reviver? CAGE (Ewing, 1984) Assessment: The whole person Social (e.g. peer groups, loss of friendships) Relationships (e.g. impact of substance use on family) Financial (e.g. cost of habit, employment status) Physical (e.g. Hepatitis C, impact on fitness) Psychological (e.g. co-occurring mental illness) Motivation: Stages of Change  Motivation: transtheroetical model Stage Description Intervention strategy Pre- Unaware of problem or Conscious raising contemplation not considering change Contemplation Becoming aware, but still Consider costs & benefits undecided Preparation Starting to take steps Increase commitment and develop plan Action Engaging in behaviour Commence change plan change Maintenance Consolidating gains Maintain successful change  Severity Substance use Description Clinical Strategy Non-user Abstinent Highlight as a strength Non-hazardous Low levels of use. Education user May not warrant (e.g. overdose, drink driving) clinical intervention Risky user Clinically significant Brief Intervention use (feedback, education) Hazardous use Substance use Intensive treatment disorder (e.g. detoxification, CBT) D&A Treatment Approaches Harm Minimization – To prevent, reduce and manage the negative effects associated with drug and alcohol use for the individual, family and community. – Recognizes that abstinence is the safest method to deduce harm, however individuals may continue to use drugs. Examples – Needle & syringe programs – Methadone – Education  Offer people hope! Its easy to fall into the trap of just lecturing clients! Relapse is not a failure to change or a lack of desire to stay well.  Final Thoughts It is difficult to change behaviours! (really difficult) Co-morbidity is extremely common (you may need to address both) Treatment should tailored to the individual (really consider the unique needs of the person)