LM 7.0: PTSD Flashcards
what are the 4 PTSD symptom domains?
TRAP
- the person experienced life-threatening trauma
- develops avoidance
- recollection
- psychological and physiological hyperarousal following the event
what is the difference between PTSD and acute stress disorder?
PTSD is diagnosed if the disturbance lasts more than one month, vs. Acute Stress Disorder (ASD), if the symptoms last less than one month
the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning in order to meet criteria for PTSD or ASD
what is defined as trauma?
- the person has experienced, witnessed or learned of an event that happened to a close family member or close friend, which involved actual or threatened death or serious injury, or sexual violence
- the person experienced repeated or extreme exposure to aversive details of the traumatic event or events (first responders collecting human remains; police officers repeatedly exposed to details of child abuse)
what is recollection?
at least 1 symptom:
- recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions
in young kids, repetitive play may express trauma themes
- recurrent distressing dreams of the event
- dissociative reactions in which the individual feels or acts as if the traumatic event were recurring
- intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
- physiologic reactivity upon exposure to internal or external cues that symbolize or resemble the traumatic event
what is avoidance?
persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness not present before the trauma
3 symptoms are needed:
- efforts to avoid thoughts, feelings, or conversations associated with the trauma
- efforts to avoid activities, places, or people that arouse recollections of the trauma
what are some of the negative alterations in cognition and mood that can be seen with PTSD patients?
- inability to remember an important aspect of the traumatic event(s) (due to dissociative amnesia not alcohol, drugs or head injury)
- persistent and exaggerated negative beliefs or expectations about oneself others or the world
- persistent distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others
- persistent negative emotional state (fear, horror, anger, guilt, or shame)
- markedly diminished interest or participation in significant activities
- feeling of detachment or estrangement from others
- persistent inability to experience positive emotion (inability to experience happiness, satisfaction, or loving feelings)
what alterations in arousal are seen with PTSD patients?
at least 2 of the following:
- difficulty falling or staying asleep
Irritability or outbursts of anger - difficulty concentrating
- hyper-vigilance
- exaggerated startle response
- reckless or self-destructive behavior
what are the 3 ways you can screen for PTSD?
- primary care PTSD screen
- clinician-administered PTSD scale (gold standard)
- PTSD checklist
what are the risk factors for developing PTSD?
- severity of trauma
- type of trauma (torture yields the highest risk of PTSD)
- prior trauma and the number of prior traumatic events
- female gender
- prior mood and/or anxiety disorders
- low education
- guilt feelings about surviving a catastrophe
lots of people have experienced sexual abuse, military combat, natural disasters etc. but not everyone develops PTSD; these are the things that are risk factors for developing PTSD after being exposed to trauma
what is the psychoanalytic theory of PTSD?
it postulates that trauma reactivates unresolved psychological conflicts, for example childhood abuse
this phenomenon leads to the person unconsciously using defense mechanisms like regression, denial, reaction information and undoing to manage psychological conflict
what is the cognitive theory of PTSD?
it postulates that the person affected cannot process the trauma and uses avoidance techniques to keep from re-experiencing it
what is the behavioral theory of PTSD?
the brain processes a traumatic experience abnormally
- trauma is the unconditioned stimulus that produces a fear response
- triggers of the traumatic memory (sights, smells and sounds) represent the conditioned stimulus
- instrumental learning will generate avoidance of both the conditioned and the unconditioned stimuli
what changes in the hypothalamus-pituitary-adrenal axis are seen in PTSD patients?
- corticotropin-releasing factor (CRF) levels are elevated in the cerebrospinal fluid of patients with PTSD
- the basal serum and urine cortisol levels are lower in people with PTSD, than those in controls.
- people with PTSD have increased hypothalamic pituitary adrenal (HPA) axis sensitivity to negative feedback from glucocorticoids
what changes in neurotransmitters are seen in PTSD patients?
- increased noradrenergic activity, expressed clinically through hyperactivity of the autonomic nervous system with increased heart rate, blood pressure and skin conductance
- abnormalities in the serotonin, GABA, glutamate systems
- abnormalities in neuropeptide Y with anxiolytic properties and endogenous opioids which appear to play a role in dissociation in PTSD
what changes in brain structure and function are seen in PTSD patients?
the medial prefrontal cortex (mPFC) hippocampus and the amygdala regulate the hypothalamus-pituitary-adrenal (HPA) axis and the autonomic response
in some people, trauma leads to persistent abnormalities in the mPFC, hippocampus, recollection of trauma and avoidant behavior
- low hippocampus volume
- high amygdala activity on functional MRI
- decreased amygdala volume in veterans with PTSD compared with those exposed to trauma and without PTSD
- structural and functional abnormalities in the mPFC
what stimulates vs. inhibits the HPA axis?
the hippocampus and the prefrontal cortex inhibit the HPA axis
the amygdala and monoamine input from the brainstem stimulate CRF activity
what is the neurobiological link with PTSD symptoms?
the mPFC should extinguish the non-adaptive fear response represented by hyperarousal, trauma recollection and avoidant behavior
in PTSD, the amygdala activity is thought to be disinhibited due to dysfunction of the mPFC
this increased CRF activity is thought to be involved in the conditioned fear response, the increased startle activity and the hyperarousal in PTSD
what things should you do when evaluating someone for suspected PTSD?
- psychiatric review of systems and history
- substance abuse
- medical history and lab workup
how long after a trauma does PTSD develop?
PTSD develops at some point after trauma
in some cases the delay in symptom onset can be of more than 10-20 years
the illness course fluctuates, with exacerbations during stressful periods
what are the positive prognostic factors of PTSD?
- rapid symptom onset
- good pre-morbid function
- strong social support
- absence of co-morbidity
factors like demographics, culture, psychiatric and medical co-morbidity, can influence the illness course in PTSD
how does age influence PTSD?
PTSD in children is underestimated. Children may present with traumatic play
adolescents may display reenactment of trauma with impulsive behaviors like sexual acting out, substance use and delinquency
physical disability due to trauma, may present a threat to intimacy in a young adult while an older adult may fear losing independence and mobility
how does gender influence PTSD?
men are more likely to be exposed to combat and violence
women are more likely to suffer assault and rape.
how does ethnicity and culture influence PTSD?
ethnicity and culture may affect treatment response
Vietnam veterans were viewed by society with contempt rather than being celebrated as heroes
rape victims may fear being isolated by family and society
African Americans may be less likely to seek treatment for PTSD, although they are likely to respond to treatment similarly to other patient groups
ethnicity may influence response to medications based on Cytochrome P450 polymorphisms
which conditions is PTSD often comorbid with?
- depression
- anxiety
- substance abuse
- somatization disorder
- suicide risk
- aggression
what are the elements of a good initial evaluation for PTSD?
- a thorough safety evaluation
- a thorough history and symptom profile
- a review of current and previous substance use
diagnosis of PTSD may be aided by using which instruments?
- PTSD checklist (PCL)
2. primary care PTSD screen
what is the baseline rate of PTSD in the general population?
8%
what % of people with PTSD will also have a substance use disorder?
50%
which biological findings have been replicated in PTSD?
- amygdala hyperactivity
- low serum cortisol levels
- hyperactivity of the autonomic nervous system
what are the principles of treating PTSD?
- evaluate for safety
- use team approach
- educate and form therapeutic alliance
- monitor medication response and manage non-adherence
- assess and manage functional impairment, physical illness, psychiatric co-morbidity
what are the goals of PTSD treatment?
- decrease symptom severity
- contort comorbidity
- avoid symptom relapse
- promote progress in development
what types of medications can be used to treat PTSD?
- antidepressants
- anticonvulsants
- antipsychotics
- benzodiazepines (not recommended)
medication for PTSD can reduce symptoms like insomnia, agitation, anxiety, irritability and psychosis, that could limit the patient’s ability to participate in psychotherapy.
what class of drugs is best for treatment of PTSD?
antidepressants
SSRIs like fluoxetine treat PTSD effectively addressing all symptom clusters
SSRIs also treat co-morbid disorders like depression and panic and address suicidal behavior and impulsivity.
tricyclic antidepressants are also effective
which anticonvulsants are used to treat PTSD and why?
- carbamazepine
- valproate
- topiramate
- lamotrigine
they are used for augmentation of treatment with antidepressants and alpha adrenergic agents
what is thought to cause nightmares in PTSD patients?
NE plays a central role in the patho-physiology of PTSD and its levels are elevated in the cerebrospinal fluid and urine of patients with PTSD
its suppression is effective in treatment of nightmares in PTSD
which medications are used to treat PTSD nightmares?
- post-synaptic alpha1 NE receptor antagonist prazosin was effective in decreasing trauma-related nightmares in patients with PTSD in placebo controlled studies; the drug was better tolerated and similarly effective with quetiapine in a sample of veterans with PTSD
- alpha2 adrenergic receptor agonist clonidine decreases sympathetic nervous system outflow through the brain and although less studied that prazosin, has been reported to decrease nightmares in PTSD
- 2nd generation antipsychotics (olanzapine, quetiapine), have been shown in case series or case-control studies to decrease nightmares and improve sleep in PTSD
what is cognitive and behavioral psychotherapy?
This type of therapy is based on cognitive processing and behavioral response to trauma-associated events. This often involves repeated exposure to trauma-associated events or reminders, in order to reduce “distorted threat appraisals”.
a common type of approach is prolonged exposure, which has the highest evidence of success among patients with PTSD. For details and an example of a prolonged exposure therapy session, please see next 2 slides.
what is EMDR psychotherapy?
EMDR = eye movement desensitization and reprocessing
EMDR is a well-established treatment modality which involves a thorough inventory of traumatic events, desensitization and processing and installation of alternative cognitions, among its eight steps
this type of treatment has strong evidence of effectiveness in adults
what is psychodynamic psychotherapy?
psychodynamic hypothesis of PTSD postulates that trauma has reactivated unresolved psychological conflicts which results in the regressive use of defense mechanisms such as repression, denial, reaction formation, and undoing
psychodynamic therapy approach to PTSD focuses on:
- strengthening patient’s capacity to cope with memories of trauma and associated triggers through supportive and insight oriented interventions
- assisting with maintenance of a functional sense of self, in the face of shattered assumptions about secure attachment and trust
what is the most psychotherapeutic treatment for PTSD?
prolonged exposurea therapy
what is prolonged exposure therapy?
it is based upon cognitive processing and behavioral principles and is considered the most effective psychotherapeutic treatment for PTSD
there are 3 components:
1. educating the patient about the rationale for exposure to feared stimuli
- patient talks through the trauma (imaginal exposure); this part of therapy pairs the hierarchy of feared stimuli with relaxation breathing exercises
- real world practice (in vivo exposure) presents the patient with a progressive hierarchy of real stimuli such as going to crowded places
over time, the patient’s reactivity to reminders of trauma decreases and so do the associated symptoms like avoidance and isolation – ognitive restructuring occurs and the patient shows less distortions related to threat appraisal
what happens during education and breathing psychotherapeutic treatment for PTSD?
the patient will be educated about the rationals of therapy, his/her symptoms will be explained and he/she will have the opportunity to set goals for the treatment along with the therapist
some of the goals can be:
1. process the meaning of trauma
- understand the difference between the traumatic memory and the traumatic event
- become accustomed with emotional response to the memory
- disprove that the exposure to trauma reminders will result in harmful consequences
- disprove the belief that anxiety will continue forever
- introduce breathing retraining to help reduce the anxiety that occurs during sessions
- patients will learn that they can manage discomfort
what is imaginal exposure psychotherapeutic treatment for PTSD?
imaginal exposure involves one describing and visualizing the trauma they experienced, as though it is occurring now; the patient will know they are in a safe place with the therapist
the therapists will help with recalling the situations that one is avoiding at present or the past intrusive memories and dreams and pairing the memories with a relaxation response
the patient is instructed to keep his/her eyes closed and talk about the details of traumatic memories or avoided situations: as if they were occurring in the present and to describe the sensations they are experiencing, and what they are thinking now
sometimes the patients will record the description of their feelings and listen to it at home and over time they’ll gradually work up to more difficult memories and describe more traumatic occurrences until those become less bothersome
what is in vivo exposure psychotherapeutic treatment for PTSD?
patients will be sked to make a list of what they are avoiding, that seems related to past traumatic situations
they will be asked to list the least to the most anxiety provoking situations and memories (hierarchy of trauma-related situations)
these situations are actually not dangerous at present, but unless confronted, they will result in continued fear and anxiety
each week the patient will confront a fearful and avoided encounter and rate their discomfort on a 10 point scale with 1 being little distress, 5 being significant distress, and 7-8 indicating rather severely disturbing distress
when confronting this situation the patient will pair this with a relaxation response
in time the fear and anxiety will habituate and diminish
which of the following medications have been shown to reduce the frequency and intensity of nightmares?
A. clonazepam
B. quetiapine
C. prazosin
D. trazodone
C. prazosin
Psychotherapy for PTSD that focuses on strengthening coping so that patients do not remain in regressed states after being exposed to reminders of trauma falls into the category of what?
psychodynamic psychotherapy
psychodynamic hypothesis of PTSD postulates that trauma has reactivated unresolved psychological conflicts which results in the regressive use of defense mechanisms such as repression, denial, reaction formation, and undoing
a patient with PTSD was asked by his therapist to close his eyes and visualize various horrific events that he encountered in combat. He was also asked to use relaxation breathing to help deal with the increase in anxiety that occurred during the exercise. This exercise if best described as an example of what?
imaginal rehearsal
What was the most highly recommended evidence-based psychotherapy option in 2010 Veterans Affairs/Department of Defense (VA/DOD) guidelines for the management of PTSD?
trauma-focused psychotherapy with exposure and cognitive restructuring components
