8- PTSD Flashcards

1
Q

DSM-5: PTSD

A

PTSD first appeared as an official diagnosis in DSM III (1980) => Prior to this: DSM I: “Gross Stress Reaction”, DSM II: “Transient Situation Disturbances”

Emerged in DSM as a response from social movements in the 1970s => Women’s movement, War veterans, Holocaust survivors

Departure from other DSM categories:

  • Trauma is the presumed common etiological factor
  • Disorder is organized around it *Highly controversial

Criteria:

  • Need exposure to a traumatic event
  • Intrusion symptoms ex: intrusive memories, dreams, flashbacks
  • Avoidance symptoms ex: trauma-related thoughts and external reminders
  • Negative alterations of cognitions and mood ex: memory impairment, negative beliefs and emotions, detachment from others
  • Arousal and reactivity ex: angry outbursts, hypervigilance, exaggerated startle response
  • Duration: > 1 month
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2
Q

Other DSM-5 Dx

A

Acute Stress Disorder

  • Same symptoms as PTSD BUT duration of symptoms is
    less than one month

Course:

  • Can be transient (i.e., remit after one month)
  • Or can progress into PTSD (or other diagnosis)

Adjustment Disorder

  • Emotional and behavioral disturbance occurring within 3 months of onset of the stressor
  • More common stressors (e.g., business or marriage problems) => Should this even be a disorder?
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3
Q

Controversies

A

1- No Longer An Anxiety Disorder => PTSD was relocated out of the Anxiety Disorders chapter and into a to a new diagnostic category

  • Argued that PTSD has non-anxiety symptoms: Dissociative experiences, Anger, guilt, shame
  • But fear conditioning seems to be similar underlying process

2- What constitutes a trauma?

Normal response to abnormal event? Abnormal response to normal, stressful event?

  • In DSM III – event had to be outside the range of “usual human experience” => Emphasis on nature of stressor
  • What events are outside the range of normal human experience? Focused on rape, earthquakes, torture, military combat => But these can be common in some places
  • Can PTSD result from events in normal range? ex: car accident
  • DSM IV got rid of “normal human experience” concept => Shift toward abnormal response to a normal event (“Conceptual bracket creep”)
  • DSM 5 focused on tightening criteria ex: Need “in person” experience (not through electronic media), Need actual/threatened death/injury (Not stressful life event ex: divorce)

3- Normal vs Abnormal Event?

Recent studies have looked at rates of PTSD following: Traumas (meeting DSM Criterion A), Stressful life events (not necessarily traumatic)

  • Do you need a full-blown trauma for PTSD? => Rates of PTSD symptoms were higher after life stressors than for traumas

4- PTSD and Depression

  • Depression is as likely an outcome following a trauma as PTSD => Stress is a risk factor for depression too
  • Close relationship between PTSD and
    depression: High comorbidity, Predict one another
  • Are they separate disorders, or do they have a common diathesis?

5- Political and Financial Interests

  • Controversy that PTSD diagnosis services political and financial purpose, rather than clinical one => Veterans Administration now required to provide services
  • Methodological Issue: Research on PTSD is often done on people with a vested interest in being diagnosed with PTSD ex: Study found lower PTSD rates among war veterans when assessed via clinical interview (4%) rather than questionnaire (21%)
  • Some studies have tried to verify trauma histories of people => 93% of Vietnam vets with PTSD had actually been in Vietnam and from those Over 1⁄2 had no documented combat exposure
  • 7% had never been in Vietnam or never been in the military
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4
Q

Epidemio

A

Prevalence rates following trauma

DSM-III: PTSD thought to be rare (3%) vs Now: Lifetime prevalence: 6.8% => But traumatic events are relatively common

  • Study found that 85% of undergrad students experienced a traumatic event in their lifetime => following trauma, 9% develop PTSD

*Traumatic event is necessary but not sufficient cause of PTSD

Gender diff => 2F: 1M

Are women more likely to experience traumatic event? => No men report more trauma (1st criterion) vs women

So, why are women less likely to have trauma but more likely to develop PTSD?

Difference in types of traumatic experiences

  • Men: accidents, nonsexual assault, combat/war, disaster, fire, serious illness, witnessing death/injury
  • Women: sexual assault, child sexual abuse => These events are more likely to contribute to the development to PTSD *Implication of human intent

BUT

  • Higher prevalence of PTSD among women is not solely attributed to differences in event types
  • Even when exposed to the same traumatic event, PTSD rates are higher in women ex: Oklahoma City bombing with 45% women vs. 23% men reported PTSD symptoms
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5
Q

Cross-Cultural Studies

A

Variability in PTSD rates across cultures => Highest in Canada

Why? Violation of expectations of safety

But, symptoms vary across cultures => “Flashbacks” may be a Western phenomenon, More somatic presentation in other cultures

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6
Q

Risk Factors

A

Pre-Trauma Risk Factors => Who is more likely to experience trauma?

  • Gender (male)
  • Occupations (ex: first responders)
  • Familial psychopathology
  • Pre-existing psychopathology (ex: depression)
  • Childhood adversity (ex: abuse)
  • Low SES
  • Low education
  • Race (Black > White)

Post-Trauma Risk Factors => Who is more likely to develop PTSD after experiencing a trauma?

Individual Differences:

  • Gender (female)
  • Pre-existing psychopathology
  • Lack of social support
  • Lower IQ => can make meaning in adapting way

Nature of Trauma

  • Proximity (to you or sme else)
  • Duration
  • Level of life risk
  • Human involvement
  • Intention ex: assault vs. accident
  • Psychological processes occurring during and after trauma
  • Dissociation
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7
Q

Biological Factors

A

Vietnam twin registry

  • Among twins who both served, 33% of variance due to genetics (controlling for combat exposure)
  • Same registry: Identical twins, one served and one didn’t => Twin who served in Vietnam much more likely to have PTSD than those who did not

*Evidence for genetic factors as well as environmental events

Hippocampus: Involved in explicit memory processes and encoding of context during fear conditioning

  • Hippocampal volumes are reduced in size in brains of people with PTSD => Smaller hippocampal volume associated with greater symptom severity (e.g., chronic, unremitting PTSD)

Scar => Most of this research is cross-sectional (correlational)

  • Are brain abnormalities observed in PTSD caused by the trauma? If so, represents a “scar” of the trauma on the brain

=> Ample evidence from animal research that severe stress can damage the hippocampus

BUT correlation does not equal causation *Not everyone who experiences even severe acute stressors goes on to develop PTSD *In fact, majority do not (Also, evidence that hippocampal volume is heritable)

=> Possible alternative explanation: Brain abnormality might be vulnerability factor to developing PTSD?

*Prospective Designs: To tackle cause/effect questions, measure biological factor in individuals prior to traumatic event and again afterwards BUT, difficult to do this

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8
Q

Twins Discordant Study

A

Identify surrogates for what the trauma- exposed person would be like if they didn’t have the experience of the traumatic event

Non-trauma exposed, identical (MZ) twin => Shares all the genes of the trauma-exposed twin, shares a lot of twin’s early developmental environment (ex: same family, community, school) BUT Non-shared environment = trauma experience (unique to exposed twin)

Study: All male; in their early 50s

  • 17 combat-exposed Vietnam veterans with PTSD (ExP+)
  • 17 non-combat-exposed co-twins of ExP+ (UxP+)
  • 23 combat-exposed Vietnam veterans with no PTSD (ExP-)
  • 23 non-combat-exposed co-twins of ExP- (UxP-)

=> Examined hippocampal volumes in each of the four groups

If HC volume is a “scar” of trauma, we would expect differences between ExP+ and UxP+
If HC volume is a vulnerability factor for PTSD, we would expect NO difference between ExP+ and UxP+

Results brain volume correl with PTSD Sx:

  • ExP+ subjects have a negative relationship between HC volume and PTSD symptom severity
  • UxP+ subjects’ HC volume ALSO predicts the severity of their exposed co- twins symptoms (twin didn’t combat able to predict their co-twin sx)
  • Combat severity not associated with HC volume

Results brain volume diff in twin pair gr:

  • PTSD group has less HC volume compared to those without PTSD (10% difference)
  • But HC volumes are smaller in BOTH ExP+ and UxP+ twins (no difference!)

CONCLUSIONS:

  • Smaller hippocampal volume in PTSD may represent a pre-existing, familial vulnerability* Doesn’t seem to be a “scar” of trauma
  • Combat exposure and hippocampal volume may represent independent risk factors
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9
Q

Psychological Factors

A

Traumatic Memories

Differences in the way that memories may be stored and retrieved

  • Traumatic: non-verbal, sensory-form
  • Non-traumatic: verbal form

=> Sensory impressions are experienced as if they are happening in the here-and- now, rather than memories from past (Can explain why talking about trauma in therapy is beneficial)

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10
Q

Cognitive Theory

A

PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat

  • Negative appraisals about the traumatic event
  • Disturbance in autobiographical memory =>

PTSD patients have difficulty intentionally retrieving memory BUT, have high frequency of involuntarily triggered intrusive memories

  • Poor memory elaboration: Memory is not adequately integrated into context => Hypothesized to be related to dissociation
  • Strong associative memory for traumatic stimuli (conditioned stimulus strong) => Also, strong link with stimuli presented before/during traumatic event
  • Strong perceptual priming for stimuli temporally associated with the traumatic event ex: tall man
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11
Q

Treatment

A

Prevention-focused strategies

  • Reduce likelihood of trauma
  • Increase coping skills (ex: stress inoculation training)

Crisis Intervention

  • Psychological first aid
  • Debriefing (ex: listening, engage, connect )

Cognitive-Behavioral Therapies*

  • Prolonged exposure
  • Cognitive reprocessing therapy
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