8 - PTSD

Question 1

What are the 4 symptom clusters in PTSD?

Answer 1

• re-experiencing
• avoidance
• disturbances in cog/mood
• hyperarousal

Question 2

What are the 8 key mechanisms involved in PTSD?

Answer 2

• emotional memory consolidation
• heightened threat appraisal + expectancy
• impaired contextualisation
• impaired fear extinction
• emotion dysregulation
• hormonal/HPA axis dysregulation
• hippocampal impairment (structure/function)
• over-active threat detection networks/impaired frontal inhibition

Question 3

Why is heterogeneity in PTSD presentations important?

Answer 3

• means we must use a case-formulation approach
• diff tx elements for diff presentations
• intrusive memories/nightmares: imaginal exposure
• avoidance: in-vivo exposure
• negative cogs: CT
• dysfunctional coping: dissociation, substance abuse, thought suppression, anger

Question 4

What clinical models are relevant to PTSD? Why are the useful?

Answer 4

FEAR LEARNING

• neutral cues associated with intense fear (often unconscious > must be made conscious)
• PTSD results from fear conditioning + impaired extinction learning
• amygdala mediates fear memory formation/storage
• central nucleus mediates fear response

NEUROBIOLOGICAL

• impaired top-down inhibition of fear/arousal networks
• impaired activation in fear extinction networks (hippo, vmPFC) + hyperactivity in fear circuits (amygdala, insula, dACC)
• REDUCED AMYGDALA RESPONSE PRE TO POST THERAPY + INCREASED MEDIAL PFC + rACC

HOW ARE THESE USEFUL?

• helpful for clients to understand unconscious learned fear associations that are triggered
• helps overcome “I am crazy” “I am weak”
• helps understand pervasive/ongoing triggering of fear responses and intrusive memories and, thus, avoidance

Question 5

Explain the cognitive model of PTSD

Answer 5

2 KEY MECHANISMS

1. TRAUMA MEMORY (FEAR CONDITIONING)
   - poorly contextualised, fragmented, lack coherent narrative, readily triggered by sensory details
2. NEGATIVE APPRAISALS OF TRAUMA + SX
   - lack of knowledge > psychoed
   - I’m crazy, emotional numbing (I’m evil, something wrong with me)
   - this was my fault, I can’t cope, I’m weak

BOTH:

• <> with current threat, intrusions, arousal, strong emo
• <> with dysfunctional coping strategies (dissociation, rumination, substance use, thought suppression, anger)

Question 6

What are predisposing factors to PTSD?

Answer 6

• premorbid anx, mood, substance use dx or family hx psychopathology
• trauma hx (interpersonal violence/sensitive periods)
• family instability during childhood (attachment)
• low social support
• female
• reduced hippocampal volume: poor contextualisation(?)
• impaired fear extinction learning

Question 7

What are post-trauma risk factors for PTSD?

Answer 7

• sx severity 1-2 weeks post-trauma (severe intrusive mems + re-experiencing)
• persistent dissociative sx
• acute elevated resting HR
• low social support
• avoidance
• rumination
• ongoing physical complications (pain = trauma reminder)
• negative interpretation/rumination about trauma and its effects > MEANING of the trauma (catastrophic appraisals)

Question 8

What are the key maintaining factors of PTSD?

Answer 8

• avoiding trauma reminders
• avoid/suppressing thoughts and memories
• negative cogs about self/world
• substance abuse
• dissociation
• rumination
• catastrophic appraisals

Question 9

Explain the evidence around catastrophic appraisals, fear extinction and PTSD

Answer 9

EVIDENCE:

• fragmented nature of trauma memories (data-driven + associated with arousal)
• sig catastrophic appraisals as a predictor and maintaining factor of PTSD
• both have an effect
• no interaction (separate effects)
• independent effects > both need to be targeted during cognitive therapy + exposure

Question 10

What things are vital to assess in PTSD?

Answer 10

• trauma details
• meaning of trauma + PTSD sx
• prior traumas (child + adult)
• ongoing threats/current stressors
• previous self-harm hx/suicide attempts
• substance use hx
• coping strategies
• social supports
• loss associated with trauma
• comorbid issues (substance use, MDD, suicidality, anx)
• range of emo responses (anger, guilt, grief)
• dissociation v. capacity to engage in emotions
• rship or substance cravings and PTSD sx (if insight)
• if multiple traumas: what trauma(s) are currently most distressing

Question 11

Explain the assessment of appraisals of sx

Answer 11

• negative appraisals of self + catastrophic appraisals of sx&raquo_space;> may impede engagement or treatment success
• identify appraisals of: sx, trauma, self
• ask open-ended Qs: how do you feel about yourself since the trauma? what does it mean for you to have these sx?

Question 12

Define trauma and explain the rates of PTSD

Answer 12

• trauma: sig threat to physical integrity; directly experienced or witnessed
• norm following trauma is recovery
• 70% of people will experience trauma but only 10-15% develop PTSD
• trauma is common, but PTSD is only one response
• most people display some PTSD sx in the initial few weeks post-trauma, but these sx reduce over time in most people
• NOTE: critical incident stress de-briefing NOT an evidence-based intervention

Question 13

What two assessment tools can you use in PTSD?

Answer 13

PTSD checklist (PCL5)

• self-report, severity ratings, 5mins
• best measure to track tx progress

Clinician Administered PTSD Scale (CAPS)

• gold-standard, semi-structured interview for diagnosis (lifetime and current), 40mins
• get frequency and severity