Being on the cutting edge of science and academic study can certainly help assess a client’s situation without getting overly involved or acting outside of the sphere of your ability (such as diagnosing a client). However, understand the various stress syndromes can assist you in understanding where your clients are at. Once you better understand why they are acting and reacting, this compassionate approach can assist you with appropriate communication skills and better boundary building. A case manager can fully benefit from understanding the kinds of stress disorders a client may be suffering from due to the situation or from past events that are now impacting on their current mood. Depending on what type of phenomenon is going on, sometimes the behavior may look like post-traumatic stress disorder (hyper-vigilance, agitation, etc) but really may be part of how the haunting is affecting the family unit. Women are more likely to talk about their emotional feelings to generalize, of course, but men in particular may not state that that have a diagnosis because they fear it may make them look less virile. It also important to note that different people react differently to the same situation because like snowflakes, we are all different. Some of us have cultural and social supports that will make us less susceptible to these effects, but there are not guarantees.
To make this as simplistic as possible, BOO!, something scary has happened. What can happen immediately or later on to a client or to a member of your team?
Acute Stress Disorder
Scientists of all types uses scales and standardized descriptions to discuss a particular pattern of events. Today the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV or V) is used for diagnosis and treatment. After this event, we shall call BOO!, Acute Stress Disorder (ASD) occurs in some individuals after experiencing of an extremely emotional or traumatic event, such as the terrorism that occurred in America on September 11, 2001. For this particular stress diagnosis, the American Psychiatric Association (APA) (2000) states that symptoms must be present in the client for at least 48 hours and up to 30 days. At this point, either the condition will have been ameliorated or the diagnosis will change.
Morrissette (2004) describes a sufferer of this disorder as “an individual who has been exposed to a traumatic event, develops anxiety symptoms, re-experiences the event, and avoids stimuli related the event for less than four weeks afterward” (p. 38). Other sources such as the APA note that symptoms may involve disassociation, depersonalization and lack of feeling or specific memories of the event. Morrissette also explains emotional, cognitive, physical and behavioral symptoms for this disorder, yet research remains relatively sparse and has mainly focused on the experiences of police and rescue personnel. The APA also notes that though there has not been a lot of research completed, the information available suggests that up to 33 percent of those exposed to a traumatic event may exhibit symptoms of ASD. Further, Morrissette states there is no journal or organization working towards creating awareness and research with this particular stress disorder. Bryant, Harvey, Dang and Sackville (1998) note that this disorder first was recognized in the last version, DSM-IV. They offered promising results on the use of an Acute Stress Disorder Interview (ASDI) to not only identify those with ASD, but also at risk for later Post Traumatic Stress Disorder. ASD is a controversial diagnosis. There are theories as to whether there is a directly connection between ASD and Post Traumatic Stress Disorder (PTSD). Some wonder whether ASD can stand as a disorder on its own, or as simply a possible precursor to PTSD. The impact of social, economic, historical, and political forces, such as terrorism have legitimized and shaped the development of this disorder’s description. A comparison of research styles and subjects before and after the terrorism attacks on September 11, 2001 show that the direction of the study of this disorder has dramatically changed.
Harvey, Bryant and Dang (1998) note the lack of specific detail recall that seems to be an identifying component of ASD. The cognitive theories will also come into play as well. Bryant, Harvey, Dang, Sackville and Basten (1998) found that cognitive behavioral therapy could be effective in treating ASD specifically. The social/interpersonal approaches will look toward external stressors such as culture and interactions with others will affect not only whether the individual acquires the symptoms of this disorder but also whether they continue to later change the diagnosis to PTSD or not. Bonanno, Galea, Bucciarelli and Vlahov (2007) found that socioeconomic factors and prior trauma exposure may have an effect on whether the individual develops a stress disorder or not.
Post-Traumatic Stress Disorder
Diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning. The Mayo Clinic Staff (2015) explains that many people do not understand that the symptoms have no start and or range of timelines. PTSD can rear its ugly head from 3 months after BOO! to years or decades later. Friendships, relationships, and work experience can become harshly affected. The four types of symptoms are memory intrusion, avoidance, negativity and emotional or mood change. According the Mayo Clinic:
Symptoms of intrusive memories may include:
• Recurrent, unwanted distressing memories of the traumatic event
• Reliving the traumatic event as if it were happening again (flashbacks)
• Upsetting dreams about the traumatic event or severe emotional distress
• Physical reactions to something that reminds you of the event
Avoidance is trying to avoid thinking or talking about the traumatic event. Avoiding places, activities or people that remind you of the traumatic event
• Negative changes in thinking and mood may include:
• Negative feelings about yourself or other people
• Inability to experience positive emotions
• Feeling emotionally numb
• Lack of interest in activities you once enjoyed
• Hopelessness about the future
• Memory problems, including not remembering important aspects of the traumatic event
• Difficulty maintaining close relationships
Changes in emotional reactions (arousal symptoms) may include:
• Irritability, angry outbursts or aggressive behavior
• Always being on guard for danger
• Overwhelming guilt or shame
• Self-destructive behavior, such as drinking too much or driving too fast
• Trouble concentrating
• Trouble sleeping
• Being easily startled or frightened
PTSD does not go away or ameliorate over time. It can become overwhelming and therapy is advised at the very least after the diagnosis by a medical professional is made.
Secondary Post-Traumatic Stress Disorder
Secondary Stress Disorder or Secondary Post Traumatic Stress disorder is also a relatively new diagnosis. It gained more recognition during the 9/11 attack on America. Just by watching the news or hearing stories from loved ones, family and friends found that they were have a disturbing change in their stress reactions. This can also occur if people lived with someone (such as a military veteran) who suffers from PTSD, they may notice themselves beginning to “mirror” some of the vet’s behaviors (Familyofavet.com, 2015). Those who are caretakers for relatives with long-term debilitating or terminal disorders or injuries (such as cancer or third degree burns)
However, it currently is not recognized by the Diagnostic and Statistical Manual of Mental Disorders.
Post Traumatic Embitterment Disorder
Another controversial category not well known or accepted in the United States is post-traumatic embitterment disorder (PTED) discovered by Linden in Germany after the fall of the Berlin wall. He studied people who were adversely affected by the re-unification of Germany that involved job displacement, and political and social confusion. These individuals had aspects of PTSD but did not adequately match the criteria. Linden (2003) offered the definition and core criteria for PTED as a legitimate subgroup of the adjustment disorders. PTED was also distinguished and differentiated from posttraumatic stress disorder (PTSD).
PTED is a universal condition that can happen after a significant, but not life-threatening event. Embitterment is different from depression, adjustment issues and PTSD in that there are issues of self-blame, feelings of revenge and injustice. It is not clear that treatment for PTSD, depression or adjustment disorder will be sufficient for these individuals, as a change of world-view or schema may be necessary for full relief. Linden offers seven areas for focus to differentiate PTED from other disorders: the life event (trigger); pre-morbid personality and functioning; subjective interpretation of the event; emotional reaction; modulation of effect; duration of the condition/symptoms; and social consequences.
Linden, Baumann, Rotter and Schippan (2008a) confirmed that patients with PTED had symptoms that included feelings of injustice, embitterment, revenge, resentment and rage. With PTED, patients rarely experience remission and continue ruminating over the negative life event. It is the level and overwhelming pre-occupation with these feelings that are characteristic of PTED. The intensity of these emotions affects the individual’s mental and physical health and general functioning. Linden, Baumann, Rotter, and Schippan, (2008b) compared PTED to other mental disorders and found that PTED can be differentiated from other diagnoses as PTED patients had less anxiety, and reported a higher rate of disability and symptomatology prior to admission. The authors note that 50 percent of PTED patients do score significantly for major depression, but the PTED patients do not have any consistent problems with affect. Further, there has to be a causal relationship in the PTED patients with the onset of symptoms and a major negative life event. Finally, while PTSD can be seen as a problem that causes feelings of anxiety, PTED can be described as one that involves feelings of revenge and injustice. One of the symptoms of PTED involves the issue of assigning blame and personal failure. While PTED patients externalize the feelings and identify them as unjust, harboring resentment and feelings of revenge, there still is a component of self-blame. Bodner and Mikulincer (1998) developed a study where participants either experienced “universal” failure or “personal” failure after being presented with some problem-solving exercises. The authors found that those who were to take the failure as a personal flaw or weakness experienced symptoms similar to depression and paranoia. There may be a relationship between attentional focus and the assigned responsibility for failure. This is also important to PTED investigation as Linden speculates that multiple events and/or past negative experiences may affect the reaction to the critical negative event.
Additional symptoms of PTED involves intrusive thoughts and ruminations. Boelen and Huntjens (2008) studied intrusive images during grieving. They discovered that intrusive events were common while grieving. The authors found that intrusions are caused by ineffective functioning in processing the loss and may lead to the negative cognitions and evasive behaviors. More frequent intrusions also appear linked to deeper grieving, depression and anxiety. Frequent death images and views of a bleak future seemed to result in anxious symptoms while re-enactment fantasies and negative thoughts of the future were linked to depression.
Those with this disorder are resistant to traditional therapy. Linden devised a form of cognitive therapy, called wisdom therapy, that works to develop new perspectives, empathy and an increase in active and positive coping behaviors. Eventually, the negative life event is evaluated, the consequences are explored, the motivation to change is illustrated and the acceptance of the reaction and feelings are encouraged. The counselor then works with the client to change. Basically, the negative life event has violated the person’s beliefs about the world and herself and this has led to doubt and humiliation. Linden stresses that the processing of the resentment and anger are important so that integration of the event can happen.
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