A Case-Study of PTSD in Infancy: Diagnostic, Neurophysiological, Developmental and Therapeutic Aspects

By Keren, Miri; Tyano, Samuel | The Israel Journal of Psychiatry and Related Sciences, January 1, 2000 | Go to article overview

A Case-Study of PTSD in Infancy: Diagnostic, Neurophysiological, Developmental and Therapeutic Aspects


Keren, Miri, Tyano, Samuel, The Israel Journal of Psychiatry and Related Sciences


Abstract: Post-traumatic Stress Disorder of Infancy has become accepted as a nosological entity. Assessment guidelines and diagnostic criteria have been defined, taking into account the impact of development on the expression of post-traumatic symptoms. Therapeutic reenactment has been considered the cornerstone of the therapeutic process. The issue of deciding what is the optimal time for therapist-induced reenactment of the trauma remains ill-defined. The less verbal and the more avoidant the traumatized infant is, the more directive the therapist needs to be, meaning he will not necessarily get clues from the infant of his readiness for reenactment. The therapist will need to introduce the trauma, at the risk of provoking a massive "flight or fight" reaction, as is illustrated by the case study of a two-and-a-half-year-old post-traumatic preverbal boy and his mother. Issues relating to conditions under which reenactment stops causing reactivation of the trauma and starts being a process of therapeutic desensitization are raised. We suggest that integration of psychodynamic and neurodevelopmental concepts might be useful in deepening the understanding of the impact of therapeutic reenactment in PTSD of Infancy.

Introduction

PTSD of Infancy is a relatively new nosological entity, with many unanswered questions relating to its developmental and neurophysiological characteristics, diagnosis and especially its treatment. In this paper, we propose first to review the major studies, and then focus on reenactment therapy through a case study of a traumatized two-and-a-half-year-old boy with his mother.

PTSD of Infancy (0-48 months): History of the Concept

The first detailed and published case of a child who suffered a life-threatening experience and was evaluated prior to 48 months of age appeared some 20 years ago (1), but was overlooked until Terr's major pioneering work on PTSD in children. Terr (2) looked at what happens to early memories of trauma in 20 youngsters who had suffered psychic trauma before the age of 5 years. She concluded that at any age, behavioral memories of trauma remain quite accurate and true to the events that stimulated them. Following this retrospective study, Terr started a series of prospective studies on school-aged children and adolescents who experienced life-threatening traumas (3-5). She defined two basic types of response (6): Type I trauma, which includes full, detailed memories, "omens," and misperceptions; Type II trauma includes denial and numbing, selfhypnosis and dissociation, and rage. Pynoos (7) defined a traumatic event for young children as any direct or witnessed event that threatened his/her own and/or his/her caregiver's physical and/or emotional integrity. This work focussed on retrospective studies and prospective follow-up of schoolage children. The response of children under 3 years of age to traumatic events remained unknown. In 1993 the first study of posttraumatic reactions in children 0 to 3 years of age (8) included case studies that indicated that infants and toddlers perceive and remember traumatic events (mostly implicit memory, which does not require conscious awareness or recall of a retrieved memory) and do develop PTSD, with many symptoms similar to those of older children and adults. The impact of developmental skills on the extent to which events become traumatic for an infant and on the phenomenology of traumatic reactions was stressed by the authors. Symptoms proposed to be the concrete manifestations of dysfunction during different periods of infant development were the following:

Age 0-6 months: Hypervigilance, exaggerated startle response, irritability, physiologic dysregulation, withdrawal.

Age 6-12 months: Any of the preceding, and/or increased anxiety in strange situations, angry reactions and more attempts to avoid specific situations (by using increased mobility), sleep disorders (mostly Stage 4 phenomena). …

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