PTSD Flashcards
What is the 12-month prevalence of PTSD
2.3%
Explain how anxiety is experienced and list the bodily associations
Normal anxiety is universally experienced in response to a threat. It’s associated with a range of cognitions and physiological responses from apprehension, intense feelings of dread, as well as hyperactive autonomic phenomena (e.g.. abd discomfort, restlessness, perspiration, palpitations).
It’s a normal reaction to an abnormal or unpredictable event.
How is trauma described in the DSM 5?
Trauma is described in the DSM 5 as the experience or the witnessing of ‘an event or events that involved actual or threatened death, serious injury or sexual violation, or a threat to the physical integrity of self or others’.
Does not have to evoke feelings of intense fear, horror and helplessness as in DSM IV
Not DSM 5:
Trauma is out of the ordinary day – day human experience e.g. not just failing exams or breaking up with partner
Rather: War, Violence, Sexual or Physical Assault, Natural disasters, Terrorism, Medical-Life threatening illness/ Medical procedures, Severe accidental injuries ( MVA, Burns)
How do you diagnose PTSD
DSM 5 (2013) classified under Trauma – and Stressor- related Disorders which includes Reactive Attachment Disorder, Disinhibited Social Engagement Disorder, Acute Stress Disorder, PTSD, Adjustment Disorders.
The expected response to a severe trauma is one of shock, fear, horror and helplessness. With time this response should disappear and the vast majority of individuals experience spontaneous recovery from these feelings. The problem arises when this spontaneous recovery fails to occur. PTSD and related pathology could thus be conceptualized as a disorder where there is failure to recover.
Define ASD
ASD is limited to the first 4 weeks after traumatic event.
List the diagnostic sx of acute stress disorder
Characterized by 9 or more of 14 symptoms from five categories
Intrusion symptoms- intrusive memories or repetitive play in kids, distressing dreams, flashbacks as though trauma recurring, intense distress/ physiological reaction in response to cues
Negative mood- persistent inability to experience happiness, satisfaction, or loving feelings (numbing)
Dissociative symptoms- altered sense of reality (depersonalization, derealisation), dissociative amnesia
Avoidance symptoms – avoid thoughts/ feelings associated with event, avoid reminders of event
Arousal symptoms – sleep difficulty, irritability and anger, hyper-vigilence, poor concentration, exaggerated startle response.
Symptoms last 3 days- 1 month; cause significant distress or impairment; not due to substance, GC or brief psychotic disorder.
PTSD DSM diagnostic criteria A
A. Traumatic event
Direct exposure
Witness in person
Indirectly, by learning that relative or close friend exposed
Repeated or extreme indirect exposure, usually in course of professional duties
PTSD DSM diagnostic criteria B
B. Re-experiencing (1)
Intrusive recollection/dreams
Distress or marked physiological reactivity on cues
Dissociative reactions
PTSD DSM diagnostic criteria C
C. Avoidance (1)
Avoid feelings, thoughts, people and places linked to event.
PTSD DSM diagnostic criteria D
Negative cognitions and mood (2)
Persistent and distorted blame of self/ others
Persistent negative beliefs & expectations of self or world
Diminished interest in activities
Inability to remember key aspects of event
Feeling alienated from others
Persistent inability to experience positive emotions
PTSD DSM diagnostic criteria E
E. Arousal (2) Poor sleep & concentration Hypervigilence and exaggerated startle Irritability or aggression Self destructive behaviour
PTSD DSM diagnostic criteria F
F. Duration
PTSD is diagnosed after 4 weeks with the presence of criterion B, C, D, E
PTSD DSM diagnostic criteria G
G. Functional significance
Must be presence of significant distress or functional impairment
PTSD DSM diagnostic criteria H
H. Attribution
Not due to GMC or substances
Aetiology of PTSD
Bio-psycho-social
Social / Environmental Factors
- Protective role of support/validation
- Endemic violence/insecurity
- Role of media
- Natural causes vs. human violence
- Shared “meaning-making” of traumatic experiences
Traumatic event primary (severity, onset, type)
Biological factors
- Genetics – familial pattern confirmed
- Neurochemistry
- Serotonin – low mood, impulsiveness
- Noradrenaline - hyper arousal
- Opiate system – numbing
- Neuroendocrine – HPA axis (Cortisol)
Brain structures involved:
Sensory input, memory formation and stress response mechanisms are affected. The regions of the brain involved in memory processing that are implicated in PTSD include the hippocampus, amygdala and frontal cortex. While the heightened stress response is likely to involve the thalamus, hypothalamus and locus coeruleus
Compare and differentiate the functioning of the prefrontal cortex in a normal brain vs a PTSD brain
Normal brain - Complex thinking, decision making and appropriate behaviour
PTSD brain - Dysfunctional thought processes and decision making; inappropriate responses to situations
Compare and differentiate the functioning of the hypothalamus in a normal brain vs a PTSD brain
Normal brain - Releases hormones like cortisol to help manage and direct efforts to stressors
PTSD brain - overactive, which leads to imbalances in hormone levels and increases stress and anxiety
Compare and differentiate the functioning of the hippocampus in a normal brain vs a OCD brain
Normal brain - Transfers and stores information into memories
OCD brain - Stores memories incorrectly and affects memory retrieval
Compare and differentiate the functioning of the amygdala in a normal brain vs a PTSD brain
Normal brain - sets off fight or flight in response to danger
PTSD brain - sets off fight or flight in response to memories or thoughts about danger
Risk factors for development of PTSD
Pre- trauma predictive factors: childhood emotional problems by age 6, personal & family history of mental illness (esp. depression and other anxiety disorders), previous trauma, lower education , lower intelligence, general childhood adversity, female gender, younger age at time trauma, minority racial/ ethnic status
Predictive factors during and after trauma: trauma severity; dissociation; lack of support; additional life stressors; development of ASD; trauma perpetrated by caregiver; and in military personnel, being a perpetrator, witnessing atrocities, or killing the enemy.
Higher risk: female; sexual vs.. non-sexual abuse; very young and very old; migration/ refugee status
Assessment and treatment in the acute aftermath- ‘ the golden hour/s’
Debriefing, which involves recall and rehearsing of the traumatic event, is not beneficial and can potentially delay recovery.
Aims of intervention in acute aftermath is to assist with maintaining emotional control, restoring interpersonal communication, and helping the person return to full functional capacity.
Goals of acute stress management
E - Reduce Exposure to stress (e.g. secure place)
R - Restore physiological needs (nutrition, pain control)
A - Provide Access to information/ orientation
S - Locate source of Support (relatives, religion)
E - Emphasise Expectation of returning to normal
What not to do in the acute aftermath
Do not pathologize - Instead rather emphasise that ‘this is a normal response to an abnormal situation’
Do not psychologize - Do not forcefully facilitate emotional reactions by e.g. group counselling or debriefing. Only provide supportive counselling to those that request it.
Do not pharmacologize - Do not use benzodiazepines etc. in the first few hours.
Treatment of acute stress disorder
‘watchful waiting’ and reassurance recommended in first 4 weeks after trauma.
No evidence for routine use of medication.
Must educate victim and carers about symptoms, when to seek help, as well as what treatments are available.
Aim is to normalize the experience and provide reassurance that only a minority of people will develop PTSD
When to seek help for ASD
- Prolonged symptoms more than 4 wks
- Significant impairment in functioning and severe, debilitating symptoms e.g. insomnia
- Symptoms out of keeping- psychosis/ suicidality
Which tool can you use as a screening tool for PTSD
Screen for symptoms using a valid and reliable tool such as the Primary Care PTSD Screen for DSM -5 (PC-PTSD-5)
A patient administered checklist for PTSD is also available - Posttraumatic Stress Disorder Checklist for DSM -5 (PCL-5)
Useful as can track response over time
Describe the tool used for PTSD (what are the questions in the tool?)
Have you ever experienced such an event? Y/N (if no then stop, if yes then proceed)
In the past month, have you…
Had nightmares about the event(s) or thought about the event when you didn’t want to? Y/N
Tried not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Y/N
Been constantly on guard, watchful, or easily startled? Y/N
Felt numb or detached from people, activities, or your surroundings? Y/N
Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? Y/N
If yes to any three of the five questions then a more detailed assessment for PTSD is warranted
List PTSD psychological therapies
Trauma-focused cognitive behaviour therapies have the best evidence base
- Prolonged exposure (PE)
- Cognitive processing therapy (CPT)
- Cognitive therapy for PTSD (CT-PTSD)
- Eye Movement Desensitisation and Reprocessing (EMDR)
- Narrative Exposure therapy (NET)
Interventions are typically 8-12 sessions long 60-90 minutes.
List the biological treatment of PTSD
SSRI’s and SNRI are pharmacological treatments of choice.
Evidence strongest for Sertraline, Paroxetine, Fluoxetine & Venlafaxine
Response seen as early as 2-4 weeks of starting medication but could take up to 12 weeks.
Benzodiazepines relatively contraindicated
Explain the course of PTSD
Duration of symptoms vary, approximately half recover completely within 3 months.
May have waxing and waning course with symptom reactivation in response to reminders of trauma
Co-morbidity (85%) is rule rather than exception: Depression, Substance abuse, other anxiety disorders, personality disorders, bulimia.
The impact of PTSD on clinicians
“Contagiousness” of trauma
Trauma fatigue / burnout
Need for introspection, self reflection
Support - individual or group
Ethical / legal concerns
Conflicts around confidentiality / child protection, military/police etc.
Advocacy role
