Post-traumatic Stress Disorder (PTSD) and People with Learning Disabilities
- Publish Date: 2013/03/05 - (Rev. 2016/10/11)
- Author: Thomas C. Weiss
- Contact : Disabled World
Outline: The psychological understanding of PTSD is that it represents a failure on the part of an individual to process their experience of fear.
The amount of literature on the subject of PTSD experienced by those who also have forms of learning disabilities is limited, begging the question of why PTSD occurring in people with learning disabilities has been understudied. One of the reasons why is because PTSD was recognized as a separate concept only fairly recently and a full acknowledgment that people with learning disabilities also experience forms of serious mental illnesses is just as recent. Disorders that are more recently described in the population as a whole take time and must be delineated and explained in people with learning disabilities. Accepting that people with learning disabilities do suffer trauma has been a hard concept for some to comprehend. It has only been recently that universal experiences such as bereavement have been recognized and studied in people with learning disabilities.
The psychological understanding of PTSD is that it represents a failure on the part of an individual to process their experience of fear, reflecting either a prior vulnerability to fear or exposure to extremes of fear. Other people experience guilt, sadness and shame. Fear shatters their inner sense of security. People who are resilient view themselves as neither helpless or omnipotent when faced with stress and are not ashamed to seek out help and use the assistance they are offered. People who are vulnerable tend to view care-seeking as something that is shameful and feel anxious. How these emotions and coping strategies are understood in people who have forms of learning disabilities remains largely unknown.
The risk of developing PTSD is related to several factors to include duration of exposure to trauma, personality, and early childhood adversity. The occurrence of depression during the months after a traumatic event is an important predictor of chronic PTSD. Complex PTSD in particular affects a person's concept of self and is associated with prolonged exposure to trauma. Early abuse is a significant factor in the development of PTSD in people who also experience a form of learning disability.
Psychopathology of PTSD and People with Learning Disabilities
Studies of PTSD in adults in the general population found the symptoms most commonly reported were a feeling of jumpiness, nightmares, and difficulties with sleeping. Half of those who experience symptoms found the symptoms lasting less than 6 months, yet for one-third the symptoms lasted more than a year. Around half of people with any symptoms experienced only one and the average was 2.3 for men and 2.5 for women. Chronic PTSD among young people presents with symptoms such as:
- Substance misuse
- Conduct problems
- Self-injurious behaviors
Substance misuse and conduct problems have the potential to obscure the post-traumatic origin of the disorder, indicating the importance of viewing the symptoms of PTSD in the context of the developmental level of the person and - for people with learning disabilities, their emotional and cognitive capacity in particular.
People with forms of learning disabilities are at an increased risk for psychiatric disorders than people in the overall population. People with mild to profound learning disabilities experience disorders similar to those affecting non-disabled persons in the general population. The largest difficulty is achieving a diagnosis because the presentations of the disorder might be different in people who experience a severe developmental delay. Due to this, the diagnosis of PTSD in people who do not have the communication skills to describe their feelings, thoughts, or mood might be hindered. At times it becomes a matter of observing changes in a person's functioning and behavior such as regressive behaviors, aggression, or changes in the person's sleep pattern. Due to the limited recognition of PTSD in people who experience learning disabilities, the symptoms might be attributed to other forms of psychiatric diagnosis.
Only one major study of adults with learning disabilities diagnosed with PTSD has been reported. The study involved a population of 51 adults and revealed that people with learning disabilities develop PTSD at a rate that is comparable to the non-disabled population when exposed to trauma. Each person had experienced at least two types of trauma; the most frequently experienced type was sexual abuse by multiple perpetrators, physical abuse, or life-threatening neglect committed with some other active abuse or trauma. Some did not involve abuse; for example, a sibling dying in a fire, witnessing a close friend die during an accident or during a seizure, or seeing a parent commit suicide by a gunshot wound to the head. All of the people involved in these instances experienced trauma involving seeing a friend, caregiver, or close relative die in traumatic circumstances.
Almost all of these adults with PTSD were referred with disruptive or violent behavior. The most common psychiatric diagnosis before the diagnosis of PTSD was either no diagnosis at all, or schizophrenia. Other more common diagnosis included autism and, 'intermittent explosive disorder.' Approximately half of the people involved someone working with them who knew of the trauma they had experienced. Them most common comorbid psychiatric condition diagnosed when PTSD was identified was - major depression.
From a Developmental Perspective
Children and teenagers who have survived life-threatening disasters experience a wide range of symptoms that often cluster around signs of re-experiencing the traumatic event, attempting to avoid dealing with the emotions that arise, and signs of increased physiological arousal. Many times they experience generalized anxiety, depression, or pathological grief reactions. The incidence of PTSD in children is around 33%-50% after a traumatic event. There are few studies that indicate the natural history of PTSD in children, although a significant number will experience symptoms 7 years after a civilian disaster.
A child's level of language development and cognition is crucial in determining how they will react to a specific traumatic experience. From a developmental aspect, preschool children are far more regressive in their behavior as well as more antisocial, demonstrating destructive behavior. Young children are able to present graphic accounts of their experiences and have the ability to report the distress they experienced in both images and thoughts.
People with forms of learning disabilities will experience traumatic events in keeping with the developmental disabilities they experience. An ongoing debate exists concerning the criteria for PTSD in children and teenagers who have experienced traumatic events. There has been an argument for developmental-state-specific diagnostic criteria for PTSD since there is some evidence that children in different developmental stages present with different PTSD symptoms. There is a need for field trials to evaluate the validity of current PTSD criteria for people with learning disabilities at different levels of functioning.
Assessing PTSD in People with Learning Disabilities
It is important to emphasize that clinicians need to be aware that PTSD should be considered in the diagnosis of a person who also experiences a learning disability who presents with a number of symptoms related to trauma. Clinicians need to ask:
- When did the trauma occur
- What is the nature of the trauma
- Is there a previous history of trauma
- What symptoms has the patient suffered
- What support and treatment have been received
If a person is presenting soon after a traumatic event it might be apparent to the clinician that symptoms of PTSD may be present. In those who experience chronic PTSD related to abuse earlier in their lives, it may be less obvious and the trauma might not be known to the person's network of contacts. A person with a form of learning disability and good communication skills might have the ability to talk about, 'flashbacks,' recurring dreams, or vivid memories. People with mild learning disabilities may have the ability and autonomy to show avoidance of circumstances that resemble or are associated with the trauma they have experienced. Unfortunately, neither of these abilities may be there in people with severe to profound forms of learning disabilities.
What is clear is that behavioral issues - especially aggression, are the most common symptoms in people with learning disabilities related to PTSD. Nightmares, sleep issues, and jumpiness are the most common symptoms reported among the population in general. If a mood disorder such as anxiety or depression are diagnosed, it must be ascertained whether or not this is in conjunction with PTSD.
One of the diagnostic criteria for PTSD is an inability on the part of the person to recall the trauma. Sadly, this might not be useful in relation to people with forms of learning disabilities who may have less experience where speaking about events in their lives or communication skills and traumatic events are concerned. What may appear to be an inability to recall details or events may not in fact be a symptom of PTSD.
The symptoms of increased psychological arousal and sensitivity must be assessed with knowledge of the person affected prior to the trauma. Sleep issues are common in people with severe forms of learning disabilities. The symptoms of irritability or anger outbursts, which might be shown as physical aggression, may be symptoms in people with learning disabilities who also experience PTSD.
Difficulties with concentrating would most likely be recognized by a loss of ability to remain on tasks that had previously been within the person's abilities. Hyper-vigilance and an exaggerated startle response may be hard to detect, although with close observation a clinician may detect an increased sensitivity and jumpiness to the person's environment. There may also be a sense of detachment from the person's environment, something that might be evident to caregivers, as well as a loss of interest in activities the person used to enjoy. People with learning disabilities who also have PTSD can experience symptoms including:
- Sleep problems
- Depressed mood
- Agitation or jumpiness
- Disruptive or defiant behavior
For people who experience significant social and communication disabilities, such as people with pervasive developmental disorders, it is still possible to assess the impact of abuse. The core symptoms of pervasive developmental disorder, such as obsessional or stereotyped behaviors, are not affected, yet other behavioral difficulties are evident. These behaviors include self-injurious behaviors, a refusal to attend school, changes in the person's activity levels, changes in their mood, or sleep disturbances. The person may become, 'clingy,' or withdraw from a social situation.
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