DSM PTSD + Canadian Clinical Practice Guidelines for Treatment of PTSD Flashcards
there are two sets of criteria for PTSD–what is the age cut off for these two sets of criteria?
age 6
criterion A for PTSD
exposure to ACTUAL or THREATENED death, serious injury or sexual violence in ONE (or more) of the following ways:
- directly WITNESSING a traumatic event
- witnessing the event, in person, as it occurred TO OTHERS
- LEARNING that the traumatic event(s) occurred to CLOSE family member or close friend–> in cases of actual or threatened death of a family member or friend, the events must have been VIOLENT or ACCIDENTAL
- experiencing REPEATED or EXTREME exposure to aversive details of the traumatic event(s) (i.e first responders collecting human remains, police officers repeatedly exposed to details of child abuse) –> does NOT apply to exposure through electronic media (i.e TV, movies, pictures) unless exposure is work related
criterion B for PTSD
presence of ONE (or more) of the following INTRUSION symptoms associated with the traumatic event(s), beginning after the event(s) occurred:
- recurrent, involuntary and intrusive distressing MEMORIES of the event(s) (in kids, may be repetitive play in which themes or aspects of the events are expressed)
- recurrent distressing DREAMS in which the content and/or affect of the dreams are related to the event(s) (in kids, may be frightening dreams without recognizable content)
- dissociative reactions (i.e FLASHBACKS) in which the individual feels or acts as if the traumatic events were recurring (may occur on a continuum with most extreme expression being complete loss of awareness of present surroundings)
- intense or prolonged PSYCHOLOGICAL DISTRESS at EXPOSURE to internal or external cues that symbolize or resemble an aspect of the traumatic event
- marked PHYSIOLOGICAL REACTIONS to internal or external cues that symbolize or resemble aspects of the traumatic event
criterion C for PTSD
persistent AVOIDANCE of stimuli associated with the traumatic events beginning after the traumatic events occurred as evidenced by ONE or both of:
- avoidance of or efforts to avoid distressing MEMORIES, thoughts or feelings about or closely associated with the traumatic events
- avoidance of or efforts to avoid EXTERNAL REMINDERS (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts or feelings about or closely associated with the traumatic events
criterion D for PTSD
negative alterations in COGNITIONS or MOOD associated with the traumatic event, beginning or worsening after the event as evidenced by TWO or more of the following:
- INABILITY TO REMEMBER an important aspect of the traumatic event (typically due to dissociative amnesia and not to other factors like head injury, alcohol, drugs)
- persistent and exagerrated NEGATIVE BELIEFS or EXPECTATIONS about oneself or others or the world (i.e “i am bad,” “no one can be trusted,” “the world is completely dangerous,” “my whole nervous system is permanently ruined.”)
- persistent DISTORTED COGNITIONS about the cause or consequences of the traumatic events that lead the individual to BLAME him/herself or others
- persistent NEGATIVE EMOTIONAL STATE (i.e fear, horror, anger, guilt or shame)
- markedly diminished INTEREST or participation in significant activities
- feelings of DETACHMENT or estrangement from others
- persistent INABILITY to experience positive emotions (i.e inability to experience happiness, satisfaction or loving feelings)
criterion E for PTSD
marked alterations in AROUSAL and REACTIVITY associated with the traumatic events, beginning or worsening after the event and evidence by TWO or more of the following ways:
- IRRITABLE behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression towards people or objects
- RECKLESS and self destructive behaviour
- HYPERVIGILANCE
- exaggerated STARTLE response
- problems with CONCENTRATION
- SLEEP disturbance
criterion F for PTSD
duration of disturbance is MORE THAN 1 MONTH
criterion G PTSD
clinically significant distress/impairment
criterion H PTSD
not attributable to substance, medical condition
what specifiers are available for diagnosing PTSD
- with dissociative symptoms (either depersonalization or derealization)
- with delayed expression
what is PTSD with “delayed expression”
if full diagnostic criteria are not met until at least 6 months after event (although some symptoms may be immediate)
what is PTSD “with dissociative symptoms”
meet criteria for PTSD and in addition, in response to the stressor, person experiences persistent or recurrent symptoms of depersonalization or derealization
*must not be attributable to physiological effects of substance or another medical condition (i.e complex partial seizures)
define depersonalization
persistent or recurrent experiences of feeling detached from, as it one were an outside observer of, one’s mental processes or body (i.e feeling as though one were in a dream, feeling a sense of unreality of self or body or of time moving slowly)
define derealization
persistent or recurrent experiences of unreality of surroundings (i.e world around the individual is experienced as unreal, dreamlike, distant or distorted)
what is a mnemonic for remembering PTSD criteria?
TIA-C2R2D
Trauma event
Intrusion symptoms (at least one)
Avoidance symptoms (at least one)
Cognition or mood symptoms (at least 2)
arousal or Reactivity symptoms (at least 2)
duration (1 month)
how many ways are there in the DSM that someone could have been exposed to trauma such that criterion A is satisfied for PTSD
4
how many possible intrusion symptoms are there for criterion B for PTSD
5
(memories, dreams, dissociative reactions, psychological distress at exposure to cues, physiological response in response to cues)
how many possible avoidance symptoms are there for criterion C for PTSD
2
how many cognition/mood symptoms are possible for criterion D for PTSD
7
(difficulty remembering, negative beliefs/expectations, distorted cognitions about cause/consequence, negative emotional state, diminished interest/participation, detachment/estrangement, little positive emotion)
how many symptoms are possible for “arousal and reactivity” in criterion E for PTSD
6
(irritable/angry outbursts, reckless, hypervigilance, startle response, concentration, sleep)
how do the criteria for PTSD differ if child affected is under age 6
combine persistent avoidance of stimuli and negative alterations in cognition into one criteria–> and only need ONE of these
also the negative alterations in cognition are different:
1. substantially increased frequency of negative emotional states
2. markedly diminished interest or participation in significant activities
3. socially withdrawn behaviour
4. persistent reduction in expression of positive emotions
also “alterations in arousal and reactivity” do not include “recklessness/self destructive behaviour” as an option
what medical incidents qualify as “traumatic events” in the DSM
a life threatening illness or debilitating medical condition is NOT necessarily considered a traumatic event
events that qualify include SUDDEN, CATASTROPHIC events (i.e waking in surgery, anaphylactic shock)
witnessing medical catastrophe (i.e hemorrhage) in one’s child or loved one would count however
does learning about death due to natural causes of a close family or friend count as a traumatic event per the DSM
no
what types of traumas may result in PTSD being especially severe and long lasting
when the stressor is interpersonal and intentional
i.e torture, sexual violence
how long might dissociative states last in PTSD (i.e flashbacks)
from a few seconds to several hours or even days
during which, components of the event are relived and individual behaves as if event were occurring at that moment
occur on a continuum–> from brief visual or sensory intrusions to loss of awareness of present surrounding
can be associated with prolonged distress or heightened arousal
how might PTSD affect children’s development
developmental REGRESSION may occur–> i.e loss of language in young children
what perceptual abnormalities may accompany PTSD symptoms
auditory pseudo-hallucinations–> sensory experience of hearing one’s thoughts spoken in one or more different voices
–> paranoid ideation may also be present
what is the projected lifetime risk for PTSD in the USA
8.7%
12 month prevalence in US adults = 3.5%
how do estimates of PTSD 12 month prevalence compare between USA and other parts of the world (europe, asia)
lower estimates of prevalence seen in Europe and most Asian, African and LA countries (around 0.5-1%)–compared to 3.5% in USA
amongst which populations are the highest rates of PTSD seen? what are the rates of PTSD amongst these populations?
survivors of rape
military combat and captivity
ethnically or politically motivated internment and genocide
*rates of PTSD of 1/3 to more than HALF of affected persons in these populations
how might presentation of PTSD differ in later life?
more likely to be sub-threshold rather than full PTSD symptoms but still assoc with substantial clinical impairment
which ethnic populations in the USA have comparatively lower rates of PTSD (when adjusted for traumatic exposure and demographic variables)? higher rates?
lower rates reported among Asian Americans
higher rates reported amongst US latinos, african americans, american indians
when can PTSD occur in the lifespan
anytime after the age of 1
when do symptoms of PTSD usually begin
usually within first 3 months of trauma
but can be a delay of months or even years before criteria are met
what is the natural course of PTSD (i.e, do people recover spontaneously, and if so, how quickly)
complete recovery within 3 months occurs in about HALF of adults
some people remain symptomatic for more than 12 months and sometimes for more than 50 years
initially, people often meet criteria for acute stress disorder immediately following trauma then progress to PTSD
list factors that may exacerbate PTSD in later life
worsening cognitive function
social isolation
declining health
in older adults, PTSD is associated with what three expressions?
negative health preceptions
primary care utilization
suicidal ideation
what is one way of understanding risk factors for PTSD
dividing them into pre-peri-and post-traumatic risk factors
list “pre-traumatic” risk factors for PTSD (10)
- childhood emotional problems by age 6 years (i.e prior traumatic exposure, or prior mental disorders)
- lower SES
- lower education
- exposure to prior trauma (esp. during childhood)
- childhood adversity (i.e family dysfunction, economic deprivation)
- cultural characteristics (i.e fatalistic or self blaming coping strategies)
- lower intelligence
- minority cultural/ethnic status
- family psych hx
- female gender
- younger age at time of trauma exposure (for adults)
what is a protective factor pre-trauma
social support prior to the traumatic event
list some “peri-traumatic” risk factors for PTSD (6)
- severity (dose) of the trauma (i.e greater magnitude of trauma the likelier is PTSD)
- perceived life threat
- personal injury
- interpersonal violence (esp. if violence by a caregiver or involving witnessed threat to caregiver in children)
- for military–> being a perpetrator, witness atrocities, killing the enemy
- dissociation that occurs during the trauma and persists afterward
list some “post-traumatic” risk factors for PTSD (6)
- negative appraisals
- inappropriate coping strategies
- development of acute stress disorder
- subsequent exposure to repeated upsetting reminders
- subsequent adverse life events
- financial or other trauma related losses
**social support is protective that moderates outcome after trauma
name a factor that moderates outcome after experiencing trauma
social support (including family stability in children)
how and why might the onset and severity of PTSD differ across cultural groups
onset and severity of PTSD may differ across cultural groups
may be due to:
1. variation in type of traumatic exposure (i.e genocide)
2. impact on disorder severity of meaning attributed to traumatic event (i.e inability to perform funeral rights after mass killing)
3. ongoing sociocultural context (i.e residing among unpunished perpetrrators in post conflict settings)
4. other cultural factors (i.e acculturative stress in immigrants)
*also the relative risk for various exposures i.e religious persecution may vary across cultural groups
*clinical expression of symptoms/symptom clusters may vary culturally, especially with regard to avoidance and numbing symptoms, distressing dreams, somatic symptoms
which gender appears to be more likely to develop PTSD
female (experiences more frequently and for longer duration than do males)
*at least some of this seems related to females having greater risk of traumatic events like rape and other interpersonal violence–> within populations exposed specifically to such stressors, gender difference inPTSD is attenuated or nonsignificant
how does PTSD/traumatic events impact suicide risk
traumatic events increase persons suicide risk
PTSD is associated with SI and SAs
ddx PTSD
- adjustment disorder
- other posttraumatic disorders and conditions
- acute stress disorder
- anxiety disorders
- OCD
- MDD
- personality disorders
- dissociative disorders
- conversion disorder
- psychotic disorders
- TBI
how do you differential acute stress disorder from PTSD
time–> acute stress disorder is sx for 3 days to one month after the traumatic event (PTSD is after one month)
how do you differentiate adjustment disorder from PTSD
either person has symptoms of PTSD but the stressor does not meet criterion A for PTSD (i.e not threatened bodily harm etc… maybe spouse left etc) OR has experienced stressor meeting criterion A for PTSD but does not meet full other symptoms for PTSD
does having PTSD increase likelihood of having another cooccurring mental illness
yes–> those with PTSD 80% more likely to have comorbidity
what comorbidities are most common amongst males (compared to females) with PTSD
SUDs and conduct disorder
what % of those military personnel returning from Iraq/Afghanistan have both PTSD and mild TBI
almost half
list some commonly comorbid conditions with PTSD
SUDs (more likely in males)
conduct disorder (more likely in males)
TBI
ODD, separation anxiety (in kids)
major neurocognitive disoder
what is the estimate lifetime prevalence of PTSD in canada
9.2%
what % of Canadians reported exposure to a significantly traumatic event
over 76%
according to the canadian guidelines, list the 5 most common forms of trauma resulting in PTSD
unexpected death of someone close
sexual assault
serious illness or injury to someone close
having a child with a serious illness
being beaten by a partner or caregiver
PTSD is associated with high rates of what other types of somatic problems?
chronic pain
sleep problems
sexual dysfunction
cognitive dysfunction
alexithymia
by how much is the risk of suicide attempts increased due to the presence of PTSD
2-3x
list 7 frequently comorbid conditions with PTSD
anxiety and related d/os
ADHD
ODD
MDD
SUD
alcohol dependence
borderline PD
with regard to PTSD prevention, is it beneficial for individuals who have been exposed to a traumatic event to engage in single or multiple session psychological debriefing after the event (if they have no been identified as suffering from any specific psychological difficulties)?
no–> may actually have an adverse effect on some people
this is from a meta analysis–> for individual debriefings only, no data for group debriefings
is there evidence for efficacy for multisession trauma-focused CBT (TF-CBT)?
YES for those with acute stress disorder or PTSD
*thus debriefing of all trauma victims is not recommended but rather, screening and treating appropriate people is preferred
*TF-CBT was more effective for prevention of chronic PTSD in thsoe with acute stress disorder or PTSD than wait list and supportive counselling options
is there evidence for the effectiveness of structured writing vs minimal intervention in the treatment of PTSD
no
is there evidence for the early use of benzos after trauma to PREVENT PTSD?
no–> may increase risk of developing PTSD
(also gabapentin/pregabalin also had no effect on this)
is there a medication that may help prevent PTSD from developing after trauma?
?propanolol–> one small RCT showed sign. decrease in severity of PTSD sx and lower likelihood of developing PTSD (but some conflicting data)
SSRIs–> sig. better than placebo for preventing PTSD symptoms according to parent reports but not child reports in RCT in kids
morphine–> cohort studies suggest early use during trauma care may reduce risk of subsequent development of PTSD in kids and adults
has psychotherapy demonstrated efficacy in treating PTSD? how does it compare to pharmacotherapy?
YES–> psychotherapy has demonstrated “significant” efficacy
meta analysis–> may be LESS effective than pharmacotherapy in improving PTSD symptoms and comorbid depression symptoms
list psychological interventions that have evidence for efficacy in the treatment of PTSD
individual TF-CBT
EMDR
stress management
group TF-CBT
prolonged exposure therapy
(other nontrauma based interventions did not reduce PTSD symptoms as significantly, i.e psychodynamic therapy).
which psychological interventions appear to be most effective in PTSD treatment
EMDR and TF-CBT–> EMDR seems to result in faster recovery while TF-CBT is more gradual
cognitive therapy approaches have been used effectively to treat PTSD followin which 3 types of trauma
sexual or interpersonal violence
civilian trauma
military trauma
what is cognitive processing therapy
treatment for PTSD
effective protocol
combines cognitive therapy and written accounts
–> data seems tos how no differences in outcomes with either component alone or with the combine protocol
is prolonged exposure therapy efficacious in treating PTSD
yes, as efficacious as CBT/other interventions
30 min imaginal exposures were as effective as 60 min in vivo exposures
is there benefit to adding cognitive restructuring to exposure therapy for PTSD?
some studies suggest exposure alone is better than the combo
large RCT showed combo significantly better than exposure alone
cognitive restructuring (when adjunct to exposure therapy) may help improve NON FEAR problems like ANGER AND GUILT (may be best for patients in whom these emotions predominate)
why might you add social emotional rehabilitation to exposure therapy in treating PTSD
does not seem to improve PTSD sx but did improve social functioning in male combat veterans with chronic PTSD
name the two currently identified limitations of CBT for PTSD
- about 1/3-1/2 patients experience substantial RESIDUAL SYMPTOMS and functional impairments post treatment, still report. meeting dx criteria at follow up, or relapse and require booster sessions
- external VALIDITY issues–> CBT for PTSD has been shown efficacious in RCTs but dearth of effectiveness studies that CBT can be generalized to many patients commonly found in clinical practice (i.e many studies exclude people with complex clinical profiles like childhood abuse histories, current SUDs, PDs, SI or NSSI, homelessness, refugees, intimate partner violence, significant dissociative symptoms) –> study found that the more exclusion criteria in a study, the larger effect size for CBT found in the study
(also numerous studies fail to reflect if people had any adverse effects from psychological treatment and whether dropout rates result from treatment demands)
is DBT useful in treatment of PTSD
when used as PREtreatment, reduced self harm behaviours allowing over 1/2 of patients to become suitable canditates for PTSD treatment
so basically, treated self harm so that PTSD treatment could occur
is there a psychological intervention that has been explicitly studied in comorbid PTSD and substance abuse
yes–> prolonged exposure
CBT seems to be useful for what type of PTSD
fear-based
what might need to be added to CBT for those with complex PTSD
a treatment module targeting affective regulation for patients presenting with c-PTSD
is combination psychotherapy + pharmacotherapy better than either alone?
conflicting results
recent RCT showed combo therapy was superior to psychotherapy alone
earlier RCTs showed combo was not superior to psychotherapy alone but was superior to pharmacotherapy alone
what medication should be considered as adjunctive treatment if engaging in trauma reactivation therapy? why?
propanolol
found to help PREVENT RECONSOLIDATION of the traumatic memory and thus decreased physiological responses and PTSD symptoms during subsequent follow up in randomized and open trials
is d-cycloserine helpful as adjunctive treatment in PTSD psychotherapy
no–> may in fact decrease response to psychotherapy
are the benefits of psychotherapy maintained long term
yes they appear to be (i.e PE follow up showed benefits at 5-10 years)
list the 4 first line medications for treatment of PTSD
Fearful People Spurn Vacations
Fluoxetine
Paroxetine
Sertraline
Venlafaxine XR
list the 3 second line meds for treatment of PTSD
Fluvoxamine
Mirtazapine
Phenelzine
list third line medications for treatment of PTSD
amitriptyline
aripiprazole
buproprion SR
buspirone
carbamazepine
desipramine
duloxetine
escitalopram
imipramine
lamotrigine
memantine
moclobemide
quetiapine
reboxetine
risperidone
tianeptine
topiramate
trazodone
name three medications that are second line as adjunctive therapy for treatment of PTSD
eszopiclone
olanzapine
risperidone
list 8 medications that can be used third line as adjunctive treatments for treatment of PTSD
aripiprazole
clonidine
gabapentin
levetiracetam
pregabalin
quetiapine
reboxetine
tiagabine
name 4 medications that are NOT recommended as adjunctive therapy for treatment of PTSD
buproprion SR
guanfacine
topiramate
zolpidem
name 7 medications that are NOT recommended in the treatment of PTSD
alprazolam
citalopram
clonazepam
desipramine
divalproex
olanzapine (only as adjunctive second line)
tiagabine (only as adjunctive third line)
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
mirtazapine
second line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
risperidone
third line mono or second line adjunctive
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
fluoxetine
first line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
olanzapine
NOT as monotherapy
yes as second line adjunctive
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
fluvoxamine
second line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
venlafaxine XR
first line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
eszopiclone
second line adjunctive
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
alprazolam
NOT recommended
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
desipramine
conflicting in guidelines–> says both third line and NOT recommended
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
buspirone
third line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
phenelzine
second line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
paroxetine
first line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
sertraline
first line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
escitalopram
third line
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
buproprion SR
third line
NOT recommended as adjunctive
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
citalopram
NOT recommended
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
clonazepam
NOT recommended
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
risperidone
second line adjunctive
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
abilify
third line adjunctive
state whether the following medication is first/second/third line, adjunctive, or not recommended for treatment of PTSD:
divalproex
NOT recommended
of the four first line agents for the treatment of PTSD, which TWO have the BESTt evidence
venlafaxine XR
paroxetine
*fluoxetine has some conflicting reports as does sertraline though they are both still level 1 (conflicting) and first line treatments–> conflicting reports may be related to types of traumas, symptom clusters, comorbidities
how does efficacy compare between mirtazapine to sertraline
one study showed mirtazapine had significantly higher response rates than sertraline in the treatment of PTSD however this was in a randomized open label trial so mirtazapine is second line
what type of drug is phenelzine
MAOI
atypical antipsychotics may be particularly helpful for which PTSD symptom cluster?
intrusion
name a medication that demonstrated efficacy for reducing trauma nightmares and improving sleep quality in the treatment of PTSD
prazosin
name a medication that may specifically help reduce flashbacks associated with PTSD
naltrexone
name a medication that may specifically improve trauma re-experiencing symptoms in the treatment of PTSD
fluphenazine
is cyproheptadine helpful in PTSD assoc. nightmares?
no–> was not effective and may actually exacerbate sleep disturbance
does ongoing SSRI therapy reduce relapse rates in treatment of PTSD
yes–> significant reduction in relapse rates compared to placebo over 6 months
what neurostimulation treatment may be effective in the treatment of PTSD
rTMS–> monotherapy or adjunct to SSRIs in those with PTSD
at least some improvements were maintained at 2-3 months post tx
(also adjunctive ECT may be helpful in patients with REFRACTORY PTSD)
is acupuncture effective in the treatment of PTSD
RCT data–> acupuncture more effective than wait list + as effective as group CBT
is CBT an effective first line option for treatment of PTSD
yes–> TF CBT, EMDR, PE, stress management therapy
does the evidence support the widespread use of early intervention with psychological strategies for prevention of PTSD
no–> debriefing of all trauma victims is not recommended
what is the approach to pharmacotherapy in the treatment of PTSD
start with one of the 4 first line agents
if response inadequate despite optimal dosing, switch to another first or second line agent, or add a second line agent
augmentation with second and third line agents may be important early in treatment to preserve even small gains achieved
