Class 6 Flashcards
Psychologically, the bottom line of trauma is a feeling of
utter helplessness.
Women prevalence vs men PTSD
women 2: Men 1
What type of trauma do men usually have
violent perpetrated by non-significant other; physical
What type of trauma do women usually have
violence perpetrated by significant other; sexual
x% of Canadian adults report some form of abuse before age 16
32%
Most prevalent form of childhood abuse
neglect
Prevalance of child abuse in mental health patients
70%
Automatic Response to Threat
12 msec: cortisol adrenaline =BP/ HR, blood flow, oxygenation, glucose
Cascade of survival responses
attach cry, flight, fight, freeze, feigned death
If the body has used an immobilizing defense,
, the nervous system does not get a cue to turn off
Amygdala keeps firing to signal persistence of threat
Catecholamines continue to be secreted, long after the threat has passed
3 main parts of brain
Humain brain: cortex, rational thinking
Mammal brain: limbic system, emotions
Reptile brain: brainstem, automatic response
Under threat, in the brain
limited access to prefrontal cortex, the reptile brain is running the show. The link between the amygdala and the hippocampus is broken. The memory gets stored in the implicit memory system by the amygdala where they’re encoded as sensations, smells, sounds, images, tastes, emotions, fragments of events
instead of in the explicit memory system in the hippocampus.
Usually brain encodes memory:
sensory input= thalamus= amygdala=hippocampus= prefrontal cortex
Amygdala has direct connection to
reptilian brain through hpa axis
After the encoded of the memory in the implicit memory system, the amygdalae acts like
a smoke detector, it sounds the alarm whenever it detects anything resembling the trauma
Truncated mobilizing defenses
Catecholamines
Hyper-responsive catecholamine system
↓ Cortisol
Hypo-responsive HPA axis
Hypervigilance
Increased startle
Hyperarousal
PTSD fMRI Findings
Smaller hippocampus Reversible with treatment Hyper-responsive amygdala During Flashbacks: R brain > L brain ↑ amygdala ↑ visual cortex ↓ Broca’s area
PTSD name all symptoms + number needed + specifiers
Intrusion: 1 Memories Flashbacks Nightmares Distress with triggers
Avoidance: 1
Internal (memories, thoughts, feelings)
External (people, places, situations)
Mood/ cognition:2
Amnesia
Neg. beliefs (“I’m bad,” “World dangerous,” “Trust no-one”)
Self-blame
Persistent negative emotions (fear, anger, guilt, shame)
Difficulty experiencing positive emotions
Diminished interest
Detachment from others
Arousal: 2 Hypervigilance Startle reflex Irritability / aggression Reckless / self-destructive behavior Poor concentration Poor sleep
Specifiers
with dissociative symptoms
with delayed onset
Scales
PCL-5 - PTSD Checklist :20 items, self report, cut-off > 33
IES – Impact of Events Scale - DSM-IV : 22 items, self-report, cut-off > 24
CAPS – Clinician-Administered PTSD Scale :30 items, clinician rated, cut-off > 20
For dissociation:
DES: self-report 28 items
MDI:L self-report 30 items, need to request it
ACE Questionnaire for childhood aversity
Complex PTSD, what kind of trauma
Child abuse, neglect, combat, urban violence, concentration camps, battering relationships, forced dislocation, and enduring deprivation.
Complex PTSD symptoms
Core symptoms of PTSD and: Emotion regulation issues: Self-harm Substance abuse Eating disorders Shoplifting, hoarding, gambling Picking, trichotillomania Outbursts
Relational difficulties: Reenactments Isolation / mistrust Abusive relationships / revictimization Therapeutic ruptures Parenting difficulties
Alteration in consciousness:DID
Adverse belief system:Negative core beliefs (“I’m bad/damaged/worthless”)
Somatic distress: Functional syndromes
Fibromyalgia, chronic pain
Non-epileptic seizures, headaches
Most important risk factors PTSD
Severity
Duration
Proximity
Pre trauma risk factors
Childhood trauma History of trauma Low SES Low education Low IQ Ethnic minority Past psych issues Past SUD Family psych history Low cortisol: Low cortisol: cortisol is what’s responsible for shutting off feedback loop of catecholamines, hpa axis is less active. high levels of catecholamines in the brain = the connection between amygdala and hippocampus gets blocked.
During trauma risk factors
Nature of trauma: Violent Sexual Death Personal Degrading External locus control: external locus of control: when we face events do we feel like we have power over them or feel like things just happen to us. internal: i have power and agency over the world Dissociation during trauma
Post trauma risk factors
ASD (50% progress)
Little support or services
Shame/guilt/doubt
Ongoing stressors
Adverse childhood experience mental health outcomes
Suicide (12 x more) Depression (5x) Addictions (5x) Alcohol use disorder (7x) Injecting drugs (10x) Linked to most psych illnesses: ALL anxiety disorders BAD Eating disorders ADHD & LD
Adverse childhood experience physical health outcomes
Heart disease COPD Cancer Liver disease Sexually transmitted diseases Obesity Autoimmune diseases Pelvic pain Migraines, headaches Unexplained symptoms
Course - PTSD
Onset mid-late 20’s Onset can be delayed by years Chronic, waxing & waning 60% respond to treatment 40% have residual symptoms Suicide (6x attempts), violence Associated with poor quality of life
Poor Prognostic Factors
Delayed onset of sympt. Delayed intervention Poor premorbid function Poor social support Severe sympt. Comorbidities Veterans Elderly / children
Comorbidity
60% of patients have > 3 Major depression in 50% Anxiety disorders Substance use disorders Personality disorders Somatization General Medical Conditions: pain, TBI, sexual dysfcn, IBS Children: ODD, ADHD, separation anxiety
Non pharmacological treatment
Therapy is the treatment of choice! Combo Therapy > Meds Combo not routinely recommended Individual & group are effective Positive literature for: VRE and I-CBT rTMS (L1)
Pharmacology
60% response rate
Poorer response in veterans
May take up to 12 wks
Maintenance 1-2 yrs
1st line
Sertraline
Fluoxetine
Venlafaxine
Paroxetine
2nd line
Fluvoxamine
Mirtazapine
Phenelzine
Adj 2nd line
Eszopiclone
Olanzapine
Risperidone
Nightmares
Prazosin for nightmares
Nabilone off-label
3 stages of stage based model
1)Safety & Stabilization
Building the foundation below your feet
2)Trauma Processing
Taking the sting out of the memories
3) Integration & Reconnection
Moving beyond
Stage 1 , 3 types of safety,
Physical safety: Substance use, self-injury, eating disorders
Environmental safety: Stable living situation, non-abusive relationships
Emotional safety: Ability to calm the body, modulate intense emotions, set boundaries
freeze gateway to
dissociation
Why do we need to assure safety in phase 1
While launching a survival response, we cannot integrate new information
Our first priority is to help the nervous system find its way back to safety
Contraindications to Trauma Therapy
Unstable housing
Recent psychiatric admission (within 3-6 months)
Active acute suicidality or homicidality
Severe unstable substance use, eating disorder, medical condition
Current ongoing abusive relationships
Goal of stage 1
Help people rediscover the resources & resilience they already have inside through
Psychoeducation
Skills
No trauma details
Stage 2 – Trauma Processing, goal
Exposure to the narrative & desensitization
Goal: Remember the trauma without getting dysregulated; integrate it into explicit memory
Why avoid benzos
right after trauma can increase the risk of PTSD because block capacity to consolidate memories = interfering with natural process
Evidence-Based Therapies
Eye-Movement Desensitization Reprocessing (L1): Processing with BLS: bls: bilateral stimulation: stay in the present, innately soothing, in dreams where in REM, recreating processing memories
Resourcing
Trauma-Focused Cognitive Behaviour Therapy (L1): In vivo exposure
Imaginal exposure
Cognitive restructuring
Narrative Exposure Therapy (L1): Lifeline
Exposure
Transcript
Prolonged Exposure
Cognitive Processing Therapy
Therapies that aren’t recommended
Supportive, dynamic, hypnotherapy
Stage 3 – Integration & Reconnection
Addressing grief, attachment wounds Re-investing in community, purpose, meaning Transition out of therapy Relapse-prevention plan Goal: Thriving
Kids below age 6:
Repetitive play in which themes of trauma are expressed
Less flashbacks, more reenactments in play
Nightmares not specific to trauma – frightening dreams
Withdrawn
Irritability is expressed with tantrums
Acute stress disorder criteria
Intrusion: Memories
Flashbacks
Nightmares
Distress with triggers
Avoidance:Internal (memories, thoughts, feelings)
External (people, places, situations)
Mood : Difficulty experiencing positive emotions
Arousal: Hypervigilance Startle reflex Irritability / aggression Poor concentration Poor sleep
Dissociation: Amnesia
Derealization / depersonalization
> 9 criteria
3 days – 1 month
Differences between PTSD and GAD
Dissociation is not a specifier
No negative cognitions
Timeline
Treatment ASD
Mass screening & debriefing is not recommended
Psychological First Aid Model
Ensure basic needs & maintain daily routine
Recruit social support
Psychoeducation about normal reactions to trauma
Monitor & identify vulnerable individuals
No pharmacological treatment is indicated
Early use of BZD can increase risk of PTSD
Some evidence for EMDR prior to 1 month
Adjustment disorder
“the presence of emotional or behavioral symptoms in response to an identifiable stressor/s, which occurred within three months of the beginning of the stressor/s. In addition, one or both of the following criteria must exist:
Distress that’s out of proportion with the expected reactions to the stressor.
Symptoms must be clinically significant. They cause severe distress and impairment in functioning.
In addition, the following criteria must be present:
The distress and impairment are related to the stressor and not because of an intensification of existing mental health disorders.
The reaction isn’t part of normal bereavement.
When the stressor is removed or the individual has begun to adjust and cope, the symptoms subside within six months.
Specifiers adjustment disorder
with depressed mood: low mood, tearfulness, hopelessness
with anxiety: nervousness, worry, jitteriness, separation anxiety
with mixed anxiety and depressed mood
with disturbance of conduct: violation of rights of others/ age appropriate societal norms, rules
with mixed disturbance of emotions and conduct
unspecified: physical complaints, withdrawal form relationships, impaired work, academic performance
