Trauma and Dissociation in Seniors
The topic of March 2022’s publications of interest is trauma and dissociation in seniors. “Seniors” are generally understood to be age 65 and above, but ranges have been broken down in some studies as follows: 65 and 74 years as youngest-old, ages between 75 and 84 years as middle-old, and those aged over 85 years as oldest-old (Lee et al., 2018). The senior population faces unique barriers to receiving adequate trauma-centered care, including the ageism bias that assumes post-traumatic stress disorder is not a disorder of the elderly (Yeager and Magruder, 2014). Nevertheless, of course, older adults can and do experience PTSD symptoms resulting from both past and recent traumas and circumstances unique to the aging experience such as “retirement, loss, isolation, changes in social or financial support, and medical or psychiatric conditions” (Averill and Beck, 2000). This months collection of POI articles present unique concerns older adults face in receiving trauma-centered care. The first of these is open access.
If you have any recommendations or requests for a specific upcoming publications of interest theme please email Jordan Arbelaez, ISSTD publications coordinator at JRA2189@columbia.edu.
References
Averill, P. M., & Beck, J. G. (2000). Posttraumatic Stress Disorder in Older Adults: A Conceptual Review. Journal of Anxiety Disorders, 14(2), 133–156. https://doi.org/10.1016/S0887-6185(99)00045-6
Lee, S. B., Oh, J. H., Park, J. H., Choi, S. P., & Wee, J. H. (2018). Differences in youngest-old, middle-old, and oldest-old patients who visit the emergency department. Clinical and Experimental Emergency Medicine, 5(4), 249–255. https://doi.org/10.15441/ceem.17.261
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Yeager, D. E., & Magruder, K. M. (2014). PTSD Checklist Scoring Rules for Elderly Veterans Affairs Outpatients. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 22(6), 545–550. https://doi.org/10.1016/j.jagp.2013.03.009
Older Adults and Trauma Centered Care
Gielkens, E., Vink, M., Sobczak, S., Rosowsky, E., & Alphen, B. V. (2018). EMDR in Older Adults With Posttraumatic Stress Disorder. Journal of EMDR Practice and Research, 12(3), 132–141. https://doi.org/10.1891/1933-3196.12.3.132 ***OPEN ACCESS***
Background
Recognition of posttraumatic stress disorder (PTSD) in older adults is often difficult due to its complicated presentation. Once recognized, trauma symptoms can, in accordance with international guidelines, be successfully treated with eye movement desensitization and reprocessing (EMDR) therapy. However, limited empirical research has been done on the expression and treatment of PTSD in older adults. This article discusses the interaction between age and pathology and summarizes the cognitive issues related to age, PTSD, and anxiety. It provides practical suggestions for how these can be addressed in treatment. Age-related challenges related to motivation are identified with practical suggestions for addressing them. The case illustrates the necessary additions and subtractions for older adults, with clear explanations and instructions.
Conclusions
The use of psychotherapy with older adults is increasing due to changing demographics, changes in service settings, and greater acceptability with rising cohorts. Nonetheless, older adults with mental disorders are less likely than younger adults to receive mental health services from mental health specialists (Bogner et al., 2009). Cohort features and characteristics are known to contribute to the underutilization of psychological treatment, as does access to appropriate care. In the case of PTSD, recognition may be complicated by under-reporting symptoms by the older adult, even though validated psychological treatment for PTSD appears to be as effective with older adults as with younger adults (Böttche et al., 2012; Cook & O’Donnell, 2005). Comorbidity with multiple psychological and somatic diagnoses are, however, more common in older adults and can complicate the PTSD picture. The positive effect of the therapy was shown to be sustained for 16 months after the treatment was discontinued. Mental health clinicians should be encouraged to consider and screen for PTSD with their older adult patients and to make inquiries into traumatic experiences and PTSD symptomatology. If identified and diagnosed with PTSD, the treatment option of EMDR could be considered.
Herrenkohl, T. I., Fedina, L., Roberto, K. A., Raquet, K. L., Hu, R. X., Rousson, A. N., & Mason, W. A. (2022). Child Maltreatment, Youth Violence, Intimate Partner Violence, and Elder Mistreatment: A Review and Theoretical Analysis of Research on Violence Across the Life Course. Trauma, Violence, & Abuse, 23(1), 314–328. https://doi.org/10.1177/1524838020939119
Background
This article reports the results of a scoping review of the literature on life-course patterns of violence that span the developmental periods of childhood, adolescence, and early and middle adulthood. We also assess the evidence on elder mistreatment and its relation to earlier forms of violence. Additionally, we draw on theories and empirical studies to help explain the transmission of violence over time and relational contexts and the factors that appear to mitigate risks and promote resilience in individuals exposed to violence.
Methods
This article summarizes a review and synthesis of the research literature on violence experienced by children, adolescents, and adults. Methods conform to those of a scoping review in which the goal is to “map relevant literature in a field of interest” (Arksey & O’Malley, 2005). Accordingly, we sought to identify and combine research relevant to several research questions, noting the strengths and limitations in published research. Articles appearing in this review were located by searching relevant databases (e.g., Education Resources Information Center, PsycINFO, PubMed, and Google Scholar) and assessing information in published reports and online resources. Inclusion criteria were broad; articles and other resources were included if they were (1) relevant to the topic of life-course patterns of violence, (2) published in a reliable scholarly journal or online resource, and (3) addressed one or more of the above-referenced research questions. Materials were excluded if they did not include information pertaining to topics of child maltreatment, dating or youth violence, and IPV or elder mistreatment. Throughout the review, we use the term “exposure” to refer to violence experienced as a victim of abuse by a caregiver or partner and to refer to violence that is witnessed when others are victimized (primarily in the home).
Results
Results suggest that encounters with violence beginning in childhood elevate the risk for violence in subsequent developmental periods. The strongest connections are between child maltreatment (physical abuse, emotional abuse, sexual abuse, and neglect) and violence in adolescence and between violence in adolescence and violence in early and middle adulthood. Persistence of violence into older adulthood leading to elder mistreatment is less well-documented, but probable, based on available research.
Conclusions
We conclude that more attention should be paid to studying developmental patterns and intersecting forms of violence that extend into old age. To eradicate violence in all its forms, considerably more must be done to increase awareness of the repetition of violence; to connect research to actionable steps for prevention and intervention across the life course; and to better integrate systems that serve vulnerable children, youth, and adults. Primary prevention is essential to breaking the cycle of violence within families and to alleviating the risks to children caused by poverty and other external factors such as social disconnection within communities.
Phelps, A. J., Lethbridge, R., Brennan, S., Bryant, R. A., Burns, P., Cooper, J. A., Forbes, D., Gardiner, J., Gee, G., Jones, K., Kenardy, J., Kulkarni, J., McDermott, B., McFarlane, A. C., Newman, L., Varker, T., Worth, C., & Silove, D. (2022). Australian guidelines for the prevention and treatment of posttraumatic stress disorder: Updates in the third edition. Australian & New Zealand Journal of Psychiatry, 56(3), 230–247. https://doi.org/10.1177/00048674211041917
Background
This paper describes the development of the third edition of the National Health and Medical Research Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, posttraumatic stress disorder and Complex posttraumatic stress disorder, highlighting key changes in scope, methodology, format and treatment recommendations from the previous 2013 edition of the Guidelines.
Methods
Systematic review of the international research was undertaken, with GRADE methodology used to assess the certainty of the evidence, and evidence to decision frameworks used to generate recommendations. The Guidelines are presented in an online format using MAGICApp.
Results/Recommendations
Key changes since the publication of the 2013 Guidelines include strong recommendations for specific types of trauma-focused cognitive behaviour therapy and conditional recommendations are made for five additional psychological interventions in adults. Where medication is indicated for adults with posttraumatic stress disorder, venlafaxine is now conditionally recommended alongside sertraline, paroxetine or fluoxetine.
Lapp, L. K., Agbokou, C., & Ferreri, F. (2011). PTSD in the elderly: The interaction between trauma and aging. International Psychogeriatrics, 23(6), 858–868. http://dx.doi.org/10.1017/S1041610211000366
Background
Because an increasingly large cohort of individuals is approaching their elderly years, there is concern about how the healthcare system will cope with the greater demands placed upon it. One area of concern is the impact of trauma and post-traumatic stress disorder (PTSD) in the aged. Although several reviews have highlighted the lack of knowledge and research on the topic, there still remain gaps in the literature. Nevertheless, some recent behavioral, endocrinological and neuroimaging studies may provide new insights into the discussion. The central aims of this paper are to summarize the etiological, epidemiological and clinical aspects of PTSD, trauma, and the elderly, and to integrate this knowledge with (i) what is known about PTSD in adults, and (ii) the behavioral, hormonal and cerebral changes associated with healthy aging.
Methods
A comprehensive search was performed with ISI Web of Science and PubMed for articles pertinent to the psychology and biology of PTSD, trauma, and the elderly.
Results
There exist both significant similarities and differences between adults and elderly with PTSD concerning cognitive and biological profile. Evidence suggests that PTSD in the elderly does not follow a simple clinical trajectory.
Conclusions
PTSD in the elderly must be considered within the context of normal aging. Strong claims about an interaction between PTSD and aging are difficult to make due to sample heterogeneity, but it is clear that PTSD in this age group presents unique aspects not seen in younger cohorts. Further research must integrate their studies with the biological, psychological, and social changes already associated with the aging process.
Averill, P. M., & Beck, J. G. (2000). Posttraumatic Stress Disorder in Older Adults: A Conceptual Review. Journal of Anxiety Disorders, 14(2), 133–156. https://doi.org/10.1016/S0887-6185(99)00045-6
Background
Issues that are salient in understanding posttraumatic stress disorder (PTSD) in older adults are examined in this review. Although this issue has received scattered attention in the literature since introduction of the diagnosis of PTSD to the Diagnostic and Statistical Manual (DSM) in 1980, it is clear that numerous conceptual and defining questions exist in our understanding of the aftermath of trauma exposure in older adults.
Methods
In approaching this issue, studies pertaining to diagnostic status as well as broader dimensions of psychosocial functioning are examined.
Results
Studies examining PTSD symptoms in individuals traumatized later in life show that older adults may experience somewhat different symptoms than those reported by younger adults after trauma exposure. In a study examining PTSD symptomatology among survivors of a train accident, Hagstrom (1995) noted that adults over age 65 reported more preoccupation with the accident, avoidance, sleep disturbance, intrusive thoughts about the accident, and crying spells compared with younger adults (ages 45–64). Individuals ages 18 to 24 showed similar symptom profiles as the older adults on these dimensions (with the exception of sleep disturbances and crying spells), suggesting that we should not expect a linear relationship between age and trauma-related symptomatology. Likewise, Goenjian et al. (1994) found that older adults who were impacted by an earthquake in Armenia reported more hyperarousal symptoms, but fewer intrusive thoughts, compared with younger earthquake survivors. Clearly, studies that focus on specific symptom profiles of PTSD in older versus younger adults can assist in helping us to identify the unique features of this disorder as they present in the elderly.
Although it is clear that similar features are reported by older adults who carry the PTSD diagnosis, there are suggestions that symptom profiles may be different in some respects as well. However, the literature has not yet evolved to the point where consistent findings indicate which symptoms are particularly salient in the elderly. Most likely, this issue can best be examined through comparison of recently traumatized individuals across the lifespan, given the innumerable research issues that arise in the study of individuals with chronic PTSD.
Conclusions
In reviewing the available literature on general psychological effects of trauma exposure, suggestions concerning those factors that predispose an individual to PTSD emerge. In particular, multiple dimensions of psychosocial functioning surface in the literature as interesting and useful factors that will assist in understanding risk and vulnerability, including pretrauma symptomatology, the availability of adequate social support networks, use of positive and negative coping strategies, and perceptions of the meaning of the traumatic event. Importantly, these are dimensions that have been identified as relevant in the development of PTSD in younger adults as well. One should not necessarily assume, however, that these processes influence older adults in the same way as younger adults. Certainly, aging brings about unique changes that deserve consideration in the study of PTSD in older adults. Hopefully, future studies will help us to develop coherent conceptual models of PTSD that account for these unique facets of the disorder as expressed in the elderly.