PTSD

Question 1

What is the relationship between personality and age?

Answer 1

• Stability or change?
• Roberts, walton and viechtbauer 2006
• With age conscientiousness and emotional stability increase especially between 20 and 40
• Openness decreases across the lifespan
• Agreeableness rises
• These changes are independent of sex
• Carstensen - individuals change their social networks - also positivity effect
• Diary studies

Personality kid of sets the limit on how happy you can be, which is basically what we all want. Maybe chasing after happiness is just down to convention.

Also sets limits around the quality of engagement you might have with relationships with people etc

Rates of various disorders (eg PTSD) go down with age. Age is protective because your social network is adjusted, a lot of factors which make sense when young don’t make sense when you’re old, such as chasing things which pay off in the future as opposed to immediate results. Older people don’t chase after future satisfaction as they have to wait, staying unhappy in the moment so that you can have more pleasure in the future. An older person doesn’t do that as they might not be there in 6 months time, they do whatver they want to do in order to make them happy right now.

Question 2

What are extreme stressors?

Answer 2

Extreme stressors are events that are potentially traumatic of that involve severe loss.

After exposure, most people will experience distress but will not develop a condition that needs clinical management

This might lead to PTSD

Examples - abuse, bereavement, car accidents - things that are out of the ordinary.

Most people have coping mechanisms but experience some distress.

Palpitations were almost a universal stress response to extreme situations such as earthquakes - heart very fast as though going to have a heart attack and very scared.

Cortisol firing, increasing HR, fight or flight. Following disasters etc this keeps occurring because baseline stress level is so high. This isn’t PTSD, it is normal stress for someone who has been in that situation - these people need to know that this is normal and they are doing well - positive coping mechanisms.

Question 3

What are two types of conditions following exposure to extreme stressors?

Answer 3

Problems and disorders that are more likely to occur after exposure to extreme stressors but that also occur in the absence of such exposure:

- Depressive disorder
- Psychosis
- Behavioural disorders
- Alcohol use and drug disorder
- Self-harm/suicide
- Other significant emotional or medically unexplained complaints

Problems and disorders that require exposure to extreme stressors:
- Significant symptoms of acute stress
- Post-traumatic stress disorder (PTSD)
- Grief and prolonged grief disorder
These often occur in combination with other conditions.

Grief is normal but prolonged grief isn’t eg a partner or a child
Some people never recover from it, the biggest mistake many clinicians make when treating people after trauma exposure is to only think of conditions specifically related to stress.

Question 4

Prevalence of mental illness after humanitarian disaster

Answer 4

Prevalence almost doubles after a disaster and normal distress is everywhere

Question 5

Symptoms of acute stress

Answer 5

• symptoms of acute stress (within one month of the traumatic event) cover a wide range of symptoms occurring in both adults and children, such as:
  
  • feeling tearful, frightened, angry or guilty
  • jumpiness or difficulty sleeping, nightmares or continually replaying the event in one’s mind
  • physical reactions (eg hyperventilation)
• These symptoms can indicate mental disorder, but often are transient and not part of a disorder. If they impair day-to-day functioning or if people seek help for them, then they are significant symptoms of acute stress.

most symptoms of acute stress are normal and transient. People tend to recover from them naturally.

Question 6

What are the three key symptom clusters following trauma?

what is the criteria for PTSD diagnosis

Answer 6

• Three clusters of traumatic stress symptoms require attention
1. Re-experiencing symptoms
2. Avoidance symptoms
3. Symptoms related to a sense of heightened current threat

• In people with PTSD, the event occurred more than approximately one month ago, at least one symptom from all 3 clusters is present, and the symptoms cause difficulties in day-to-day functioning.

Question 7

What is re-experiencing symptoms after trauma?

Answer 7

• These are repeated and unwanted recollections of the traumatic event.
• 3 types of re-experiencing symptoms:
  
  • An intrusive memory is unwanted, usually vivid, and causes intense fear or horror.
  • A flashbacks is an episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks lose touch with reality, usually for a few seconds or minutes.
  • Frightening dreams
• In adults, the frightening dreams must be of the event or of aspects related to the event.
• In children, re-experiencing may involve frightening dreams without clear content, night terrors or trauma specific re-enactments in repetitive play or drawings.

Remembering things to the point that it affects you to the point of interfering with everyday life e.g. have to leave a shop as distressed

Question 8

What are avoidance symptoms?

Answer 8

• These include purposely avoiding situations, activities, thoughts or memories that remind the person of the traumatic event.
  
  • a person may not want to get in a car after a road accident
  • a rape survivor may all the time try to avoid thinking of the rape.
  • the person may wish not to talk about the event with the health-care provider
• Paradox: trying very hard not to think of something, makes one think more it.

Question 9

What are symptoms related to a sense of heightened current threat?

Answer 9

• Affected persons may feel constantly in danger,

• Hypervigilance:  exaggerated concern and alertness to danger 
	
• Exaggerated startle response: being easily startled or jumpy - reacting with excessive fear to unexpected sudden movements or loud noises. 
	○ Eg person reacts much more strongly than others and takes considerable time to calm down.

Question 10

What are features associated with PTSD?

Answer 10

• All ages
  
  • Anxiety, depression, anger
  • Numbing, insomnia
  • Medically unexplained complaints
• In adolescents and adults
  
  • Alcohol and drug use problems
• In adolescents
  
  • Risk-taking behaviour.
• In children
  
  • Regressive behaviours, such as bedwetting, clinging and temper tantrums.

Question 11

What is the importance of communication in individuals following trauma?

Answer 11

COMMUNICATION SKILLS
• People who have traumatic stress may avoid communicating about traumatic events because talking about it may trigger re-experiencing symptoms.
• Important to ensure confidentiality when discussing traumatic and private issues.
• E.g. people often have great difficulty talking about sexual violence and torture.
• Never pressure the person to talk about the issue.
• It is very important to listen if the person wants to talk about the issue.

Emphasize the importance of talking about the traumatic experience at the pace with which the patient is comfortable. People may be very reluctant to talk about what happened. Talking about the stressor may make the person very emotional. It may take some time to build the trust necessary for the person to talk to someone about the stressor. People may take weeks or months before they are ready to share

Question 12

What symptoms apply to DEP and STR presentations?

Answer 12

• Low energy
• Sleep problems
• Anxious or irritable mood
• Medically unexplained somatic symptoms
• Difficulties in carrying out work

Question 13

Assessment of individuals following traumatic events…

Answer 13

1. Significant symptoms of acute stress
2. PTSD
3. Grief
4. Prolonged grief disorder
5. Concurrent conditions

Question 14

What is management of acute stress symptoms?

Answer 14

Relaxation, breathing exercises, doing things you like to do, talking about what has happened to you if its something you want to do.

Don’t force people to talk if they don’t want to.

Attend to peoples basic needs if they are in distress whatever that might be.

Help people to connect with family or other people that could help them.

Safe places to stay.

Dot give medication generally for stress disorders although there might be a pressure to do this.
Managing stress disorders like insomnia by breathing exercises, avoid coffee, avoid tv, routine etc.
There are specific techniques for dealing with bedwetting.
Cycle education is explaining to the person that this is a stress response and that external factors can make your heart go faster as a response, this is not a heart attack. Explaining why stress might cause you to get more cold etc.

Question 15

What is PFA?

Answer 15

Psychological first aid
• Psychological first aid is a humane, supportive response to a fellow human being who is suffering and who may need support
• All health workers should be able to provide very basic psychological first aid.

Question 16

What is STR psychological first aid?

Answer 16

• Key actions:
  
  • listen to the person without pressuring them to talk.
  • provide practical care and support without asking intrusive questions.
  • assess needs and concerns.
  • help the person to address immediate, basic physical needs (e.g. shelter for the night).
  • help connect to services, family, social supports and accurate information.
  • As far as possible, protect people from further harm.

Question 17

Addressing current psychological stressors (STR)

Answer 17

• Sometimes the trauma is ongoing (eg domestic abuse) or can lead to a whole new range of stressors (eg refugee camp life).
• Ask about current psychosocial stressors and as far as possible, use problem-solving techniques to help the person reduce major psychosocial stressors or relationship difficulties,
• Assess and manage any situation of abuse (e.g. domestic violence) and neglect (e.g. of children or older people).
• As appropriate, Identify supportive family members and involve them as much as possible.

Explain that providing assistance with current psychosocial stressors may help to relieve some of the symptoms.
Explain that the health care worker should involve community services and resources as appropriate (eg with the person’s consent). It may be necessary and appropriate to contact legal and community resources (eg social services, community protection networks) to address any abuse (eg with the person’s consent).
Ask the group for some other examples of ways that the healthcare worker might help with psychosocial stressors.

Question 18

Problem solving in 6 steps (following trauma)

Answer 18

Identify and define the problem
Analyse the problem
Identify possible solutions
Select and plan the solution
Implement the solution
Evaluate the solution

Not all problems can be ‘solved’

Question 19

How can we strengthen positive coping methods and social supports?

Answer 19

• Encourage the person to seek the support of trusted family members, friends or people in the community.
• Build on the person’s strengths and abilities.
  
  • Ask what is going well.?
  • What are some methods to cope with hardship that have worked in the past?
• Encourage resumption of social activities and normal routines as far as possible
  
  • school attendance, family gatherings, outings with friends, visiting neighbours, social activities at work sites, sports, community activities.
• Alert that use of alcohol and drugs does not help recovery and can lead to new problems.

Question 20

Insomnia as a symptom of acute stress (within 1 month of the event)

Answer 20

• Apply general management strategies for symptoms of acute stress. In addition:
  
  • Rule out or manage external causes (e.g., noise) and physical causes (e.g. physical pain).
  • Ask for the person’s explanation of why insomnia may be present.
  • In adolescents and adults, consider relaxation techniques and advice about sleep hygiene (regular bed times, avoiding coffee and alcohol).
  • Explain insomnia is a common problem after experiencing extreme stressors.
• If the problem persists after one month, re-assess for and treat any concurrent mental or physical disorder.

Explain that we DO NOT prescribe any psychotropics for symptoms of acute stress.
The only exception to the rule is for insomnia and only in exceptional circumstances as outline in the next slide.

Question 21

Pharmacological management of insomnia

Answer 21

In exceptional circumstances only

• In exceptional cases in adults when psychologically oriented interventions are not feasible, short-term treatment (3-7 days) with benzodiazepines (e.g., diazepam 2-5 mg/day, lorazepam 0.5-2mg/day) may be considered for insomnia that severely interferes with daily functioning.
• Precautions:
  
  • Risk of dependence. Only prescribe benzodiazepines for insomnia for a very short time and in exceptional cases.
  • In the elderly, use lower doses (e.g., half of adult doses).
  • Do not prescribe benzodiazepines for insomnia during pregnancy and breastfeeding or in children and adolescents.

Note that the suggested duration is short and the suggested dose is low, and that these should prescribed in exceptional cases.
The named medicines are on the WHO Model List of Essential Medicines.

Question 22

Bed-wetting as a symptom of acute stress in children

Answer 22

• Apply general management strategies for symptoms of acute stress. In addition:
  
  • Obtain history of bedwetting (to confirm whether the problem started only after the event). Rule out and manage possible physical causes.
  • Manage carers’ mental disorders and psychosocial stressors.
  • Educate carers. Explain that they should not punish the child for bedwetting. It may make the symptoms worse.
  • Consider training parents in the use of simple behavioral interventions (e.g., rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep). The rewards can be extra play time, stars on a chart, etc.
• If the problem persists after one month, re-assess for and treat any concurrent mental or physical disorder.

Bed-wetting is one of the classic features associated with conditions specifically related to stress.
If the problem persists after one month, re-assess for and treat any concurrent mental or physical disorder. CONSULT A SPECIALIST if there is no concurrent mental disorder or if there is no response to treatment of a concurrent mental disorder.

Question 23

Management of PTSD

Answer 23

• Assess for and address current stressors
• Psycho-education for PTSD
• Stress management
• Referral for CBT or EMDR
• DEP 3 Anti-depressants
• Strengthen coping and social supports.

Question 24

INT referral for CBT or EMDR

Answer 24

• Cognitive-behavioural therapy (CBT) and eye movement desensitization and reprocessing (EMDR) are 2 psychotherapeutic techniques that have good evidence for PTSD.
• Other therapies (whether psychotherapeutic or pharmacological) do not have such evidence basis for PTSD.
• Refer for CBT or EMDR, if competent (trained and supervised) CBT or EMDR therapists are available. Are they available here?

CBT and EMDR should be considered when the person is within a safe environment, i.e. there are no ongoing traumatic events and the person is not at imminent risk of further exposure to traumatic events. Expert opinion is divided about their appropriate use in unsafe environments.

Question 25

DEP 3 antidepressants

Answer 25

• Research shows that antidepressants in most people with PTSD only have a small effect (they tend to work on average a bit better than placebo).
• In adults, only consider antidepressants when CBT, EMDR, or stress management prove ineffective or are unavailable.
• In children and adolescents, NEVER offer antidepressants to manage PTSD.

It is assumed that the workshop participants have previously learned how to prescribe anti-depressants (through training of the mhGAP –IG Depression module)

Question 26

Frequency of follow up after traumatic events

Answer 26

• For symptoms of acute stress (i.e within 1 month of event)
  
  • Follow up is needed after 1 month in case person is not improving.
  • At follow up, assess for a range of conditions, incl. PTSD.
• For PTSD
  
  • Follow is also needed after 2-4 weeks to see whether management is working.
  • Long-term follow up at regular intervals may be necessary.
• For grief
  
  • Follow-up is needed 6 month after loss to assess for prolonged grief disorder.
• Follow up may be done in different ways (e.g. in person at the clinic, by phone, or through community health worker).

Question 27

What to do at follow up after traumatic events

Answer 27

• Monitor improvement by asking the person and family
• Ask about and possibly address ongoing psychosocial stressors
• Monitor adherence, response and side effects of medications, if prescribed
• Provide more psychoeducation