Lecture 10 - PTSD

Question 1

PTSD - Description

Answer 1

• Description – trauma is damage to a person’s psychological health and wellbeing, involving feelings of fear, sadness, guilt, anger, anxiety, and/or grief, with associated sleep and diet changes. Initial distress will probably dissipate; ongoing distress impacting daily functioning is not a ‘normal’ response. PTSD is prolonged and severe distress and ongoing difficulties following a traumatic experience – reliving, physiological arousal, avoiding reminders, and negative thoughts and feelings.
  
  • Prevalence – 50-75% of people have experienced a traumatic event (60% of men, 51% of women). However, only 5-10% of people will experience PTSD (8% men, 21% women). 12 month prevalence 4% in Aus. 15-25% of those who have experienced a traumatic event will develop PTSD.

Question 2

PTSD - Assessment

Answer 2

• – huge variability in what is experienced as traumatic. Screening for traumatic events should be done in all assessments as it can underlie broader psychopathology.
  
  • Stressful Life Events Screening Questionnaire (SLESQ) – 13 items with good psychometrics. Very (probably too) detailed questions.
  • Life Events Checklist – 17 items, self-report or clinician administered. Good psychometrics.
  • Clinician Administered PTSD Scale for DSM-5 (CAPS-5) – dichotomous and continuous. Lifetime/current/weekly forms. Excellent psychometrics. 40-60 minutes to complete.
  • PTSD Symptom Scale Interview Version (PSSI) – higher sensitivity. Good psychometrics. 20 minutes to complete, and assesses impairment in a wide variety of domains.
  • Short PTSD Rating Interview (SPRINT) – good psychometrics. 10 questions. Quick snapshot good for screening. Lumps all the symptom clusters together and doesn’t look at intensity/severity.

Question 3

PTSD - Diagnosis (7)

Answer 3

• exposure to actual or threatened death, serious injury, or sexual violence either directly, witnessed in person, indirectly through learning it has happened to a close family member or friend (violent or accidental in terms of death), and repeated or extreme indirect exposure to aversive details of the event.
  
  • Re-experiencing symptoms 1+ – recurrent, intrusive, and involuntary memories; recurrent, distressing dreams; dissociative reactions; intense or prolonged distress after exposure to reminders; or marked physiological reactivity after exposure to trauma stimuli.
  • Avoidance 1+ of trauma-related memories, thoughts or feelings or avoidance of reminders of the trauma.
  • Negative alterations in mood or cognitions 2+ - inability to recall key features of the traumatic event; persistent negative beliefs and expectations; persistent distorted cognitions about the cause of consequences of the traumatic event; negative trauma-related emotions; diminished interest in previous activities; feeling alienated; constricted affect.
  • Alterations in arousal or reactivity 2+ - irritable or aggressive behaviour; self-destructive or reckless behaviour; hypervigilance; exaggerated startle response; problems in concentration; sleep disturbance.
  • 1+ month, significant distress or impairment.
    
    • Specifiers – dissociative symptoms (depersonalisation/derealisation). With delayed expression (full diagnosis not until 6 months after the event).
      *

Question 4

PTSD - DS% Changes, comorbidity, differential diagnosis

Answer 4

• – anxiety can have arousal and intrusions and avoidance. Depression has negative emotions and cognitions and diminished interest. Personality disorders can have interpersonal difficulties and risk taking. Dissociative disorders – difficulty recalling, flashbacks, detachment, derealisation. Conversion – trauma is common. Psychotic – flashbacks/hallucinations. TBI – traumatic event, memory loss, trouble concentrating, mood disturbance.
  
  • Adjustment Disorder – emotional or behavioural symptoms in response to a stressor occurring within 3 months, with marked distress or impairment. Beyond normal bereavement. 2-4% 12 month prevalence. Onset is immediate and duration is brief. Stressor does not need to be of any specific severity, can spontaneously remiss, non-specific symptom profile. Similarities – AD can be diagnosed when full criteria for PTSD are not met or when no serious trauma has been experienced.
    
    • Acute Stress Disorder – 3 days-1 month after trauma. 9+ symptoms overall, not in specific clusters. Both reactions to trauma and have re-experiencing, avoidance etc.

Question 5

PTSD - EBT

Answer 5

• CBT – significantly greater improvement than TAU, significantly fewer symptoms than WL. Strong support across traumas – exposure component most important. Imaginal & in vivo exposure + cognitive restructuring had the greatest effects.
  
  • Working relationship over 10-15 sessions.
  • Psychoeducation – normalise the trauma reaction. Understanding of symptoms and understand the rationale for treatment.
  • Anxiety management training – coping with heightened arousal. Immediate relief for distress, increases self-efficacy, tolerating arousal needed for exposure. Mindfulness breathing, PMR, visualisation, distraction.
  • Exposure – desensitisation, elaboration of memory through conceptual processing. Remembering the trauma, re-experiencing through triggers, and avoiding situations. Retelling the story completely and visualising, focusing on details for full activation, distress rated using SUDS. Listens to the story back on tape repeatedly until SUDS falls. Cues can be presented until anxiety reduces.
  • Cognitive restructuring – changing maladaptive meanings associated with the trauma, the self and the world. Balanced and rational view of the world. Overgeneralisation, all or nothing thinking, personalisation, underlying assumptions, dysfunctional schemas.
• Medication – SSRIs, SNRIs. Paroxetine (SSRI) most effective – enhances exposure work.
• Other treatments – EMDR (strong support but controversial), psychological debriefing (potentially harmful, disrupting natural processing).
  
  • CBT for Adjustment Disorder – CBT and MBCT. Need to reduce the stressor and/or improve the person’s ability to cope. Psychoeducation, cognitive components (challenging thoughts, increase problem solving), behavioural components (monitoring, anxiety management), building social supports (support and therapy groups as well as existing support).

Question 6

PTSD - Challenges

Answer 6

• – resistance to doing exposure work. Failure to become anxious during exposure. Becoming overwhelmed with anxiety. Failure to habituate. Non-compliance.
  
  • Vicarious trauma – incorporating client’s memories into your own and experiencing PTSD symptoms. SELF-CARE IS ESSENTIAL.
  • Need to assess each trauma individually