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1999 Posttraumatic Stress Disorder Winston Seegobin George Fox University, [email protected]

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Thunberg, U. H., & Kemph, J.P. (1977). Common emo­ Many factors contribute to postpartum onset tional reactions to surgical illness. Psychiatric Annals, mood disorders. Physical exhaustion from the preg­ 7 (1). 39-58. nancy and labor probably plays a role, as does the accompanying dehydration. Within a few days af­ G. MATHESON ter delivery, the mother's hormone levels drop Postpartum Depression. Postpartum depression, abruptly, and estrogen levels in particular have been as it has traditionally been known, is now called linked to mood. major depressive disorder with postpartum onset. Psychological pressures on new mothers and fa­ The postpartum onset specifier may also be applied thers are significant. Both must cope with the phys­ to bipolar disorder (I or II) or brief psychotic dis­ ical demands of parenting, with sleep disruption order. Thus postpartum symptoms may appear as increasing the difficulty. They must learn to com­ depression, mania, or psychosis. municate with the baby and in a new way with each The common feature is onset within four weeks other. They may be ambivalent about their new of the birth of a child in women who do not have family status and roles, and the baby may bring fi­ either cyclothymia or dysthymia. Postpartum mood nancial and emotional pressures. episodes with delusions or hallucinations may be The most effective treatment appears to be post­ more common with a first birth, and 30% to 50% partum counseling within a few days of the birth. of women who have had one such episode have an­ Women who know that they should expect their other with subsequent deliveries. emotions and attitudes to fluctuate for awhile can The symptoms of postpartum onset mood dis­ anticipate recovery in two to three weeks. Those orders and nonpostpartum mood disorders are the who do not may need clinical treatment for a mood same. However, the course of the symptoms may disorder. vary more in postpartum depression, and the moods P. D. YOUNG are frequently less stable. For a diagnosis of post­ partum onset depression, a depressed mood or loss See DEPRESSION. of pleasure or interest in nearly all activities must last for at least two weeks, accompanied by at least Posttraumatic Stress Disorder. Posttraumatic four other symptoms affecting appetite, sleep, ac­ stress disorder (PTSD) is a psychological disorder tivity level, self-concept, or thinking. precipitated by exposure to a traumatic event or a Mothers with a postpartum onset mood disor­ series of events. This event is usually experienced der may contemplate suicide and may be obsessed by an individual. However, PTSD can also develop with thoughts of the new child being injured or as a result of observing or hearing of a traumatic killed. They may find it difficult to concentrate, and event occurring in someone else's life (such as a rel­ they may be physically agitated. ative or a close friend). PTSD was introduced as a If delusions are present, as they are in as many disorder in 1980 in the DSM-III. The DSM-Ill-R's as 1 in 500 births, they are usually about the baby. condition for diagnosis was the experiencing of a As the delusions may be that the baby is possessed traumatic event that was "outside the range of usual by a demon or has special powers, a pastor or Chris­ human experience." However, in DSM-IV, the fo­ tian therapist may be especially helpful. Christian cus is not so much on the nature of the event as it counselors may be well prepared to assist women is on the individual's response to the event and his with postpartum depression who feel guilty about or her vulnerability to developing the characteris­ being depressed at a time when others are telling tic symptoms. them that they should be happy. Clinical Picture. Individuals with PTSD expe­ New mothers who do not have a postpartum on­ rience three categories of symptoms-intrusive rec­ set mood disorder may experience some of the same ollections, avoidant-numbing symptoms, and hy­ symptoms, but these so-called baby blues typically perarousal. Reexperiencing the trauma through last for less than one week after the birth. Clini­ intrusive recollections such as flashbacks and night­ cians should consider a diagnosis of a postpartum mares, in which the individual involuntarily feels onset mood disorder only if the symptoms (espe­ or acts as though the events were recurring, are cially those of severe anxiety, repeated weeping, considered the hallmark symptoms of PTSD (Cal­ and lack of interest in the new baby) persist for houn & Resick, 1993). The nightmares are usually more than one week. Lack of interest must be dis­ replications of the traumatic event, whereas flash­ tinguished from lack of attention or awareness, backs are evidenced by extreme physiological and which may indicate delirium during the postpar­ emotional arousal in which the individual feels im­ tum period rather than depression. mobilized and becomes unaware of his or her sur­ Postpartum mood episodes may be severe. Es­ roundings. The intrusive recollections are triggered pecially if they are accompanied by delusions or by specific events that resemble or symbolize some hallucinations, they may interfere with developing aspect of the trauma: an anniversary, the sound of a bonding relationship with the baby and may even a gunshot, weather conditions, a particular scent, lead the mother to attempt to kill her infant. clothing, or location. For instance, a woman who 889 Posttraumatic Stress Disorder

was raped in an elevator would breathe quickly and trauma, inadequate coping skills, poor stress toler­ begin to sweat upon entering one. ance, and insufficient social supports (Tomb, 1994). Individuals also tend to avoid stimuli related to Diagnostic Criteria. In order to make a diag­ the trauma. Conscious efforts are made to avoid nosis ofPTSD, theDSM-N criteria require that the feelings, thoughts, and activities related to the trau­ individual be exposed to or have a history of expo­ matic events. Individuals also resist talking about sure to a "traumatic event" or events that involve the trauma because it brings up recollections of the actual or threatened death or serious injury or a events. The numbing behavior is usually evident threat to physical integrity. These events include through a lessened response to the outside world military combat, natural or manmade disasters, ac­ that occurs soon after the traumatic experience. In­ cidents, violent assaults (sexual abuse, rape, kid­ dividuals no longer enjoy some of the activities they naping, torture), and diagnosis with a terminal dis­ were previously interested in and maintain distance ease. The immediate response to these events is fear, from others. They have difficulties labeling their helplessness, or horror. Witnessing the events or feelings or trusting others, and they often feel that learning about them occurring with family mem­ the future is meaningless. Individuals may also ex­ bers or close friends rather than directly experi­ perience problems recalling important aspects of encing them is also included in the criteria. Other the event because of their tendency to avoid the symptoms include persistent reexperiencing of the anxiety aroused by memories of the events. For traumatic event, avoidance of stimuli that are re­ some individuals, dissociation may occur; they be­ lated to the events and feelings of numbness, and come amnestic about the feelings and memories of increased arousal. These symptoms must occur for the trauma. They also feel anger toward those who more than one month and cause severe impairment were responsible for the events, ashamed of their in social, occupational, and other areas of func­ feelings of helplessness, and guilty about what they tioning. The diagnosis is "acute" when the symp­ did or failed to do. These feelings of anger, avoid­ toms have occurred for less than three months, ance, guilt, and shame may cause them to feel iso­ "chronic" when the symptoms persist for three lated and demoralized (American Psychiatric As­ months or longer, and "with delayed onset" when sociation, 1994; Long, 1996; Tomb, 1994). the symptoms begin six months after the occurrence These individuals also become easily startled or of the trauma. If the symptoms of anxiety occur physically aroused, responses that were not pres­ within one month after being exposed to the trau­ ent prior to the trauma. They experience symptoms matic event, the diagnosis is acute stress disorder of anxiety as evidenced by difficulties falling or stay­ (American Psychiatric Association, 1994 ). ing asleep because of the nightmares they repeat­ Treatment. Treatment should occur immedi­ edly experience. Individuals also tend to be hyper­ ately after the traumatic event occurs or as soon as vigilant about their environment. For instance, rape possible after its occurrence. Three significant goals victims continually scan their environment watch­ of therapy are to establish a safe, trusting environ­ ing for potential rapists. Other symptoms include ment so that the individual can talk about trau­ irritable feelings, uncontrollable anger, and prob­ matic material; to explore traumatic material in lems with concentrating and finishing tasks. sufficient depth so that the individual can gradu­ The symptoms usually take a different form with ally integrate intrusive recollections with avoidant children. They experience nightmares about mon­ symptoms; and to assist the individual in discon­ sters rather than traumatic events. They reenact necting from the trauma and working on reestab­ the events in compulsive play and daydreams and lishment of relationships with family and friends often complain of headaches and stomachaches. (Friedman, 1996; Herman, 1992). The therapist's They also regress to more infantlike behaviors and genuineness, warmth, and empathy aid the patient forget toilet training. Separation anxiety, fear of in this process by his or her confidence about the strangers, and school phobias are not uncommon. treatment and ability to understand the significance Defiant, passive, or clinging behaviors also occur of the trauma. Various approaches to treatment are (American Psychiatric Association, 1994; Long, common. The psychodynamic approach focuses 1996; Tomb, 1994). on altering destructive attributions and reinter­ Etiology. Disagreement exists concerning there­ preting the experience and involves gradual con­ lationship between particular predispositions and frontation of the patient's feeling of shame, help­ the probability of developing PTSD. However, the lessness, and vulnerability. The behavioral approach likelihood that a stressor will produce PTSD is emphasizes how the patient can cope with present greater if the stress is sudden, severe, unexpected, symptoms and problems through exposure, rather prolonged, repetitive, life-threatening, humiliating, than uncovering the story of the trauma (Tomb, isolating, causes physical damage, and destroys one's 1994). Eye Movement Desensitization and Repro­ community and social support system. Individuals cessing (EMDR), a relatively new and controver­ seem to have a higher risk of developing PTSD if sial treatment that uses rapid rhythmic eye move­ they have a previous psychiatric disorder, a family ments, shows some promise (Shapiro, 1989). Many history of psychiatric illness, a personality style such trauma victims also find group treatment helpful as introversion, personality disorders, a history of (Tomb, 1994). 890 Poverty, Psychological Effects and Counseling

References dren from economically disadvantaged homes are American Psychiatric Association. (1994). Diagnostic and disproportionally represented in special-education statistical manual ofmental disorders (4th Ed.). Wash­ classes and experience more grade retention. Re­ ington, DC: Author. search indicates that poor families tend not to pro­ Calhoun, K. S., & Resick, P. A. (1993). Post-traumatic mote cognitive development in their homes. Lower stress disorder. In D. H. Barlow (Ed.), Clinical hand­ socioeconomic mothers are more controlling and book of psychological disorders. New York: Guilford. disapproving and give less attention to their children Friedman, M. J. (1996). PTSD diagnosis and treatment than do middle-class mothers. In problem-solving for mental health clinicians. Community Mental Health situations, lower-class mothers spent less time on a Journal, 32, 173- 189. Herman, J. L. (1992). Trauma and recovery. New York: Ba­ task than do middle-class mothers. Lower-class moth­ sic Books. ers were more likely to intrude physically and give Long, P. W. (1996, June). Post-traumatic stress disorder. negative feedback, while the middle-class mothers The Harvard Mental Health Letter. gave more nonspecific suggestions and used thought­ Shapiro, F. (1989). Eye movement desensitization: A new provoking questions. Lower-class mothers are more treatment for post-traumatic stress disorder. Journal likely to use commands and less likely to praise their of Behavior Therapy and Experimental Psychiatry, 20, children than are middle-class mothers. These style 211-217. differences places the lower-class child at risk for Tomb, D. A. (Ed.). (1994). Post-traumatic stress disorder. academic achievement, which often leads to further The Psychiatric Clinics of North America, 17 (2). behavioral and motivational problems. W. SEEGOBIN Other studies have found that socioeconomic status significantly predicted mental ability (using See TRAUMA; STRESS. Bayley Scales of Children's Abilities and Wechsler Preschool and Primary Scales oflntelligence). Sev­ Poverty, Psychological Effects and Counseling. eral other academic areas studied with school-age Low socioeconomic status has been consistently children have discovered the following significant associated with a range of risk factors, including correlations: socioeconomic status and grade point chronic stress, unemployment, and poor mental average, socioeconomic status and reading and health. In an epidemiological study Bruce, Takeuchi, math achievement, socioeconomic status and math­ and Leaf (1991) demonstrated a causal link between ematics achievement test scores, and socioeconomic mental disorder and poverty by examining the pat­ status and academic achievement. The potential terns of new disorders that developed over a six­ role of inherited mental ability in determining aca­ month period. Significant proportions of new demic success has been recognized and many stud­ episodes of mental disorder could be attributed to ies controlled for the effect of parental intelligence poverty. This article will examine three areas in quotient (IO) and education. These studies still find which poverty greatly compromises mental health low-socioeconomic children performing more and the delivery of mental health services. poorly than high-socioeconomic children even when Poverty and the Developmental Needs of Chil­ they match on parental IQ and education. Poverty dren. Profound effects of poverty have been discov­ during the toddler/preschool years is a significant ered on the psychological development and mental predictor of decline in academic achievement dur­ health of children. Families living in poverty are less ing elementary school. Academic failure is signifi­ able to obtain adequate housing, health care, and ed­ cantly related to teenage pregnancy and school ucational and social services. They are more likely to drop-out, which limit future employment oppor­ experience the highest levels of stress and yet pro­ tunities. "Poor children, then, may be doubly hand­ cure fewer social and community support services. icapped. If they live in inner cities, the schools to The indirect consequences of poverty are also perni­ which they must go are likely to be deficient in re­ cious. These often invisible effects operate within the sources and ineffective as learning institutions. But homes, challenging marital and parent-child rela­ their home environments, too, are likely to be de­ tionships. Experiencing chronic stress can alter a par­ ficient in those qualities and resources that pro­ ent's ability to nurture and parent responsibly. This mote children's learning" (Neal, 1996, pp. 344-345). easily leads to generational cycles of both poverty and Homelessness. Homelessness is defined as hav­ distressed parenting. Each new generation, reared ing no shelter, living in shelters or missions, living by parents facing debilitating circumstances and lack­ as transients in cheap hotels or rooming houses, or ing a solid foundation for thoughtful parenting, in staying with family or friends on a temporary ba­ turn finds itself lacking the emotional and social tools sis (Belcher, 1988). According to a recent National necessary to nurture its own offspring. Many poor Institute of Mental Health (NIMH) report (Sargent, families are headed by single mothers, which not only 1989), mental illness is quite high among homeless adds to the financial problem but also requires one populations. Approximately one-third of those who person to do the emotional and physical work of two. are homeless are suffering from severe mental ill­ All of these stresses compromises adequate parenting. ness, including schizophrenia, bipolar disorder, or Parental poverty is related to a host of behavioral severe depression. The report also recounts that and academic shortcomings in the children. Chil- 35% to 40% of these homeless mentally ill individ- 891