6. Trauma and Stress Related Disorders

Question 1

What is the criteria for diagnosing PTSD?

Answer 1

PTSD is HARD

Exposure to a prior trauma (witness or actual exposure to death/injury or integrity to self/others), which causes:

1. Hyperarousal: hard time sleeping/concentrating, irritable, hypervigilence
2. Avoidance of stimuli associated with trauma
3. Rexperiencing event (nightmares or flashbacks)
4. Negative cognitions/distress: blame self/others, detached from others, ↓ interest in activities and cannot remember key aspects of events

That lasts >1 month with significant distress or impaired functioning

Question 2

Treatment of PTSD

Answer 2

1st line:

1. CBT/cognitive processing therapy: support groups and EMDR (eye movement desensitization and reprocessing)
2. SSRIs
3. Venlaxine

Question 3

Patients with PTSD have an ↑ risk of:

Answer 3

1. Substance abuse: benzos (xanex) and alcohol

Question 4

What is the criteria for diagnosing [acute stress disorder]?

Answer 4

• Same criteria as PTSD, however the symptoms last 3 days => 1 month

Question 5

What is the criteria for diagnosing [adjustment disorders]?

Answer 5

Emotional symptoms (anxiety/depression) that occurs within 3 months of an idenfiable stressor (divorce/illness) lasting less than 6 months. If symptoms las > 6 months => GAD.

• Cause significant stress that is out of proportion with stressor and causes impairment of stressor.

Question 6

What types of adjustment disorders can occur?

Answer 6

1. AD + depressed mood: low mood, tearful, feeling of hopeless
2. AD + anxiety: nervous, worry, jittery, seperation anxiety
3. AD + mixed anxiety and depressed mood
4. AD + disturbance of conduct (acting out being an asshole)
5. AD + mixed disturbance of emotions and conduct

Question 7

What are the types of Somatoform Disorders?

Answer 7

1. Somatic Symptom Disorder
2. Illness Anxiety Disorder (Hypochondriasis)
3. Conversion Disorder
4. Pain Disorder
5. Body Dysmorphic Disorder (now under OCD in DSM-V)
6. Somatoform Disorder, NOS

Question 8

In Somatoform Disorders,

1. Symptoms and motivation are:
2. Physical symptoms cause: ___________
3. Symptoms are/are NOT intentionally produced or feigned.

Answer 8

1. Symptoms and motivation are unconscious/ not done for desire
2. Physical symptoms cause significant distress and impairment
3. Symptoms are NOT intentionally produced or feigned.

Question 9

What are the criteria for diagnosis of Somatic Symptom Disorder?

Answer 9

Somatic symptoms that last longer than > 6 months that cause distress, persistent thoughts and anxiety

Question 10

Treatment for Somatic Symptom Disorder

Answer 10

Regular office visits with the same doctor + Psychotherapy

Question 11

What are the criteria for diagnosis of Illness Anxiety Disorder/Hypochondriac?

Answer 11

• Preocupation with a undiagnosed illness, despite having mild – no somatic symptoms that lasts longer than > 6 months.
  
  • Patient has repeated health related behavior: repeatedly checks signs of illness.

Question 12

What are the criteria for diagnosis of Conversion Disorder/ Functional Neurological Symptom Disorder?

Answer 12

Sudden onset of voluntary sensory/motor dysfunction (neurological: mutism, blindness, seizures, paralysis), usually after a psychological stressor, however, neurological WU is NL.

1. Sx are NOT intentionally produced
2. Sx are NOT fully explained by general medical condition, substance, culturally behavior.
3. Sx cause clinical significant distress/impairment
4. Sx or deficit is not limited to pain or sexual dysfunction; does not occur during course of Somatization disorde

Question 13

RF for Conversion Disorder

Answer 13

F, adolescent, young adults

Question 14

What is a characteristic of patients with Conversion Disorder?

Answer 14

Patient shows La belle indifference: aware of, but lack of concern towards symptoms

Question 16

What are the types of factitious disorders?

Answer 16

1. Factitious Disorder on self (Munchausen syndrome)
2. Factitious Disorder on others (Munchausen syndrome by-proxy)

Question 17

Factitious disorders

• Symptoms are ______; Sx are done ______ out of desire for ____
• Patient ______ creates __________ and for _______ gain.
  
  1. Patient feels better in sick role or it resolves internal conflict: patient is afraid to go to work or afraid to be alone and loves the attention they get at hospital
• Patients are often willing to do what?

Answer 17

1. Symptoms are intentional/falsified; Done consciously out of desire for attention
2. Patient consciously creates physical and/or psychological sx (self-inject feces or saliva) /exaggerate a REAL illness to assume a sick role and for Primary / internal gain.
   
   1. Patient feels better in sick role or it resolves internal conflict: patient is afraid to go to work or afraid to be alone and loves the attention they get at hospital
3. Patients are often willing to go in for tests and surgeries

Question 18

What is the criteria for diagnosis of Munchausen syndrome?

Answer 18

Chronic factitious disorder where patient creates bizzare/unusual symptoms/illness for primary/internal gain.

Characterized by:

• 1. hx of multiple hospital admissions
• 2. willingness to undergo invasive procedures.

Question 19

What is the criterai for diagnosis of Munchausen Syndrome by-proxy

Answer 19

Production of intentional symptoms in ANOTHER person so the other person assumes a sick role.

Question 20

RF for Munchausen Syndrome

Answer 20

• F, unmarried and healthcare workers

Question 21

What is the motivation in Munchausen by-proxy?

Answer 21

Assume a sick role by-proxy

Question 22

What is the treatment in Somatoform Disorders?

Answer 22

1. Well-established therapetuic relationship
2. Team based approach: pain management, neuro and psych
3. CBT
4. Hypnosis
5. Anti-anxiety meds (clonazapam)

Question 23

What medication is best for somatoform disorders?

Answer 23

Anti-anxiety (clonazapam)

Question 24

What is malingering?

Answer 24

1. Patient consciously fakes/exaggerates or claims disorder for secondary/external gain (avoid work, obtain compensation), and stop after gain (vs factitious disorder)
2. Patient has poor compliance with treatment and F/U

Question 25

In malingering:

1. Symptoms and motivation are: _______
2. What is their compliance with treatment and F/U?

Answer 25

• Symptoms and motivation are: intentional
• Compliance with treatment and F/U: Poor

Question 26

What is the difference between malingering vs facittious disorders?

Answer 26

• Factitious disorders:
  
  • 1. Done for primary/internal gain: attention/sympathy;
  • 2. Sx do not stop after gain
  • 3. Undergo treatments and surgeries
• Malingering:
  
  • 1. Done for secondary/external gain: avoid work, obtain compensation.
  • 2. Sx stop after gain
  • 3. Poor F/U and treatment

Question 27

What are the dissociative disorders?

Answer 27

1. Dissociative Identity Disorder
2. Depersonalization/derelealization disorder
3. Dissociative Amnesia
4. Dissociative Fugue

Question 28

Generally, what are dissociative disorders and how is it different from psychosis?

Answer 28

• Dissociative disorders: Detachment from reality (feel abnormal stimuli/sensation, but know that sensation and stimuli are not real. Thus, still know what reality is), causing them to feel like theyre outside own body or become another person.
• Psychosis, which is the loss of reality = hear voices/ see things

Question 29

What is criteria for diagnosing Dissociative Identity Disorder (Multiple personality Disorder)?

Answer 29

2 or more distinct personalities with their own behavior, memory and thinking that are observed by others or reported by patient, often occuring after childhood trauma/abuse (especially sexual abuse before 6 YO).

1. Gaps in memory about events
2. Sx cause distress/problem functioning

Question 30

Dissociative Identitiy Disorder

1. More common in:
2. Most commonly occurs after:
3. DID is has a HIGH RATE OF what co-morbid disorders?

Answer 30

1. Women
2. Childhood trauma (***sexual abuse BEFORE 6YO)
3. High rate of co-morbid disorders with:
   
   1. PTSD (up to 100%);
   2. Depression and substance abuse (96%);
   3. Avoidant and borderline personality disorder

Question 31

What is the criteria for diagnosis of

Depersonalization/ derealization disorder?

Answer 31

Depersonalization = Persistent feeling of detachment from self (“Like I was in a dream”/ “Like I am watching myself”), which may cause them to lose control over actions

Derealization = detachment from world (patients are not detached from body, but world around them seems strange: unreal, foggy, visually distorted)

1. Often triggered by trauma
2. Sx must cause significant distress/impairment
3. In both, reality it intact (unlike psychosis) = patients know that sensations are NOT real.

Question 32

What is the criteria for diagnosis of

Dissociative Amnesia/ psychogenic amnesia?

Answer 32

Inability to recall important personal information/autobiographical memory (past events, job, where they live), after a traumatic event.

1. Memories can come back
2. Patient often not bothered by lack of memory
3. Amnesia not explained by other cause

Question 33

How is dissociative amnesia different from simple amnesia?

Answer 33

1. Includes large groups of memories: name, job and home
2. Due to stress/ trauma

Question 34

How is dissociative amnesia different from repression?

Answer 34

• Repression = repress a certain event (abuse);
• DA = loss of autobiographical memory (name, job, home), after trauma

Question 35

What is dissociative fugue?

Answer 35

Patient who has dissociative amnesia develops dissociative fugue = sudden wandering/traveling in that dissociated state.

Question 36

What is Trichotillomania?

• • Presents as:
• • MC in:
• • Treatment:

Answer 36

• Compulsive pulling out of ones own hair, causing distress and persists even though patient tries to stop.
• Presents with: thinning of hair/baldness in any are of the body, MC in scalp.
• MC in: childhood, but spans all ages
• Tx: Psychotherapy is 1st line; meds (clomipramine) can be considered.