lecture 7- PTSD Flashcards
explain the changes to the current dsm for PTSD
Major changes (in addition to being moved to own ‘chapter’)
* Some initial criteria far more explicit in what constitutes a traumatic event
* Examples of new inclusions/exclusions:
o Sexual assault specifically included
o Recurring exposure also added (might apply to police officers or first responders)
o Response of ‘intense fear, helplessness or horror’ now excluded
DSM-5 changes
* DSM-5 now lists 4 clusters, instead of 3 (DSM-IV TR)
o Re-experiencing event, heightened arousal, avoidance, and negative thoughts and mood or feelings
* DSM-5 includes two new subtypes
o PTSD Preschool Subtype (children < 6)
o PTSD Dissociative Subtype
* Predominant experiences of feeling detached from one’s own mind or body
* Where world seems unreal, dreamlike or distorted
* We will focus on main aspects of PTSD
explain the dsm for PTSD
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
o 1. Directly experiencing the traumatic event (TE)
o 2. Witnessing, in person, TE(s) as it occurred to others
o 3. Learning that TE(s) occurred to close family relative/friend
o 4. Experiencing repeated or extreme indirect exposure to aversive details of TE(s) – (e.g. first responders)
* Presence of one (or more) intrusive symptom associated with TE(s) beginning after the event…
o 1. Recurrent, involuntary, and intrusive distressing memories…
o 2. Recurrent distressing dreams… Content/affect related to TE
o 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if TE recurring…
o 4. Intense or prolonged psychological distress at exposure to cues…
o 5. Marked physiological reactions to internal and external cues…
* C. Persistent avoidance of stimuli associated with the traumatic event (beginning after the event…), as evidenced by one or both of the following:
o 1. Avoidance of or efforts to avoid distressing memories, thoughts or feelings about or closely associated with event…
o 2. Avoidance… external reminders (people, places, objects…) that arouse memories …
* D. Negative alterations in cognitions and mood associated with event… at least two from:
o 1. Inability to remember an important aspect of the event
o 2. Persistent and exaggerated negative beliefs or expectations about oneself, other, or the world
o e.g. “I am bad” or “The world is completely dangerous”
o 3. Persistent, distorted, cognitions about cause or consequences
o Leads to blame self or others
o 4. Persistent negative emotional state (fear, anger, guilt)
o 5. Markedly diminished interest/participation significant activities
o 6. Feelings of detachment or estrangement from others
o 7. Persistent inability to experience positive emotions
* E. Marked alterations in arousal and reactivity… at least two from:
o 1. Irritable behaviour or angry outbursts (little or no provocation)
o 2. Reckless or self-destructive behaviour
o 3. Hypervigilance
o 4. Exaggerated startle response
o 5. Problems in concentration
o 6. Sleep disturbance
o F. Duration of disturbance (Criteria B, C, D and E) more than one month
o G. The disturbance causes clinically significant distress or impairment…
o H. Disturbance is not attributable to the physiological effects of a substance or another medical condition
describe acute stress disorder
PTSD diagnosis can only be made after 1 month of symptoms
o For shorter periods, Acute Stress Disorder is more likely
o Much the same symptoms – just less persistent
* Important to treat ASD – reduce likelihood of developing PTSD
explain some stressors affecting people with PTSD
PTSD diagnosis restricted to ‘exceptionally threatening and distressing events’
o So ‘everyday traumatic events’ don’t apply
* Divorce, loss of a job or failing an examination
* Extreme reaction to these may be ‘adjustment disorder’
* Key factors
o Loss of life (or potential loss)
o Threat to life or to personal integrity
o Emotional responses (guilt, shame, intense anger or emotional numbing…)
explain some traumatic evevents which may lead to ptsd
Whole journal issue on PTSD (J Clin Psychiatry 2001, 62, Supp 17)
* Natural disasters
o Floods, tsunami, earthquakes, hurricanes, tornados..
o Rescue workers can be prone to PTSD as witnesses
* Abuse
o Domestic violence, rape, incest, emotional abuse
o 60-75% of sexual violence victims experience PTSD
* Child abuse
o Incest/physical/emotional abuse
o Childhood rape survivors 60% lifetime risk PTSD
* People diagnosed with terminal/life-changing illnesses
* Childbirth complications and trauma
o Potential loss of life (mum or baby)
o Unexpected outcomes (e.g. unplanned caesarean)
* Members of the armed forces, emergency personnel…
* Combat and war-related
o Soldiers (and other service personnel)
* War veterans can show chronic PTSD decades later
o Citizens
o Refugees
* Traffic accidents
o Road, rail, air, sea…
explain what is meant by a vulnerability for ptsd
Many people experience trauma
o But who is more likely to develop PTSD?
* May depend on subjective perception of traumatic event (in addition to objective facts)
* Someone threatened with a replica gun
o But believe about to be shot… may develop PTSD
* Not just those directly affected by horrific event
o Also applies to witnesses, perpetrators and those who help PTSD sufferers
explain why environmental and social factors may cause a vulnerability for PTSD
Severity, duration and proximity
o PTSD more likely for:
* Soldiers on front line
* Or if taken prisoner
* Those repeatedly and violently raped over long periods
* Rather than those less violent or shorter
o Social support
* Those who have social support likely to recover more quickly
* Discuss feelings
* Emotional support
explain why Psychological factors may cause a vulnerability for PTSD
Psychological factors
o Shattered assumptions
* Many hold assumptions about themselves and the world
* World is meaningful and just: things happen for a reason
* Good things happen to good people: bad things…
* A sudden trauma can shatter those assumptions
o Pre-existing distress
* PTSD more likely to develop in those with existing anxiety and depression
explain why coping styles may cause a vulnerability for PTSD
oping styles
o Negative coping styles increase likelihood of PTSD
* Self-destructive or avoidant strategies
* Drinking alcohol
* Self-isolation
* Dissociation
* Detachment from trauma
o Positive coping styles reduce likelihood PTSD
* Making sense of trauma
* Look for reasons for event
* God’s will?
* Popular with psychodynamic and existential theorists
* Gain sense of mastery (Freud
explain why biological factors may cause a vulnerability for PTSD
Biological factors
o Physiological hyperactivity
* Increased activity shown in several brain areas (PET/MRI)
* Esp. areas involved emotion regulation, fight-or-flight and memory
* Amygdala overactive in those with PTSD
* Hippocampus shrunken in PTSD patients
o Hormones and neurotransmitters
* Resting levels of cortisol lower in PTSD patients
* Cortisol shuts down SNS activity after stress
* Increased epinephrine and norepinephrin
explain 2 ways of measuring PTSD
Structured clinical interviews
o Structured Clinical Interview for DSM-5 (SCID)
* SCID DSM–IV before that (First et al, 1995)
o MINI International Neuropsychiatric Interview (MINI; DSM 5)
* Most evidence focuses on MINI for DSM-IV (Lecrubier, et al 2009)
o Clinician-Administered PTSD Scale (CAPS; Blake et al, 1995)
o PTSD Symptom Scale – Interview version (PSS–I; Foa et al, 1993)
* Self-report scales
o Impact of Event Scale (IES; Horowitz et al, 1979)
o Impact of Event Scale – Revised (IES–R; Weiss & Marmar, 1997)
o Post-traumatic Diagnostic Scale (PDS; Foa et al, 1997)
o Davidson Trauma Scale (Davidson et al, 1997)
o PTSD Checklist (Weathers & Ford, 1996)
what is the prevalence of PTSD
Estimated UK prevalence: men 2.6%; women 3.3% (McManus, et al., 2007)
* Risk (incidence) of developing PTSD after traumatic event
o 8.1% for men; 20.4% for women (Kessler, et al., 1995)
* Risk in urban populations higher
o Overall risk 23.6% (Breslau et al, 1991)
o 13% for men; 30.2% for women (Breslau et al, 1997)
explain and evaluate a Pharmacological treatment of
Pharmacological
o See Shalev,2001 – short review in J Clin Psychiatry issue
o Or Ipser et al 2006 for more extensive review
o Benzodiazepines
* Not generally recommended
* Withdrawal can make PTSD symptoms worse
* Increased risk of co-dependence with alcohol/drugs
* Such abuse not uncommon in PTSD patients
o TCAs (e.g. amitriptyline) * Some evidence of self-rated symptom improvement
* But no evidence improving anxiety
* Generally negative outcome in RCTs
o Monoamine oxidase inhibitors (MAOIs)
* Evidence also not strong in RCTs
o SSRIs
* Much better evidence of symptom improvement
* Often regarded as 1st line treatment
* Particularly paroxetine and sertraline
o Antipsychotic medication
* Atypical antipsychotic medication may improve symptoms
* May be useful if SSRIs fail
explain a psychological treatment for PTSD (behavioural)
Direct-exposure
- Client repeatedly exposed to feared stimuli
- Those most associated with original event
- May have been ‘conditioned’
- Taught to relax during recall of events
explain a psychological treatment for PTSD (cognitive)
- Focus on ‘feelings’ during recall
- Rape victims may be asked to describe attack in detail
- War veterans may recall through ‘virtual reality’ video
- Highly effective symptom reduction
