PTSD Week 7 Flashcards
PTSD is characterized by ?
intrusive thoughts, nightmares and flashbacks of past traumatic events, avoidance of reminders of trauma, hypervigilance, and sleep disturbance, all of which lead to considerable social, occupational, and interpersonal dysfunction
The diagnosis of PTSD can be challenging because of ?
the heterogeneity of the presentation and resistance on the part of the patient to discuss past trauma
What is the most frequent type of trauma experienced by women with PTSD?
sexual assault
Some causes of PTSD
Sexual relationship violence Interpersonal-network traumatic experiences (illness of child, sudden death of loved one) Interpersonal violence Exposure to organized violence Participation in organized violence combat
pathophysiology of PTSD unclear but studies using MRI’s have shown what in PTSD pts?
that there is decreased volume of the hippocampus, left amygdala, and anterior cingulate cortex
cardinal features of PTSD
relate to psychologically re- experiencing the traumatic event, increased autonomic arousal, (particularly on exposure to environmental triggering stimuli or reminders of the event) leads to intense fear, helplessness or horror
then what happens as a result of the intense arousal from certain stimuli?
pts compensate for such intense arousal by attempting to avoid experiences that may begin to elicit symptoms; this can result in emotional numbing, diminished interest in everyday activities, and, in the extreme, may result in detachment from others
how long do sx have to last before you can dx?
1 month
PTSD included in the general structure of DSM-V 5
anxiety disorder
ICD-10 billing code
F43.1
what is The PTSD checklist (PCL-5)? What score do you need to dx PTSD?
a 20-item self-report measure, can be used to screen patients for PTSD and monitor the severity of symptoms over time. A score of 38 (out of a maximum score of 80) to dx. Also must be 6yrs or older
PTSD is commonly accompanied by
comorbid psychiatric conditions, including depression, substance use disorders, and somatization
Diagnostic criteria for PTSD include:
experiencing or witnessing a severe, traumatic event resulting in symptoms in each of four categories (intrusion, negative alteration in mood and cognitions, avoidance, and arousal); social or occupational impairment; and symptoms and impairment lasting at least one month after the trauma.
acute stress disorder
Prior to 1 month of sx, patients with PTSD- like symptoms and functional impairment are diagnosed with this
clinical manifestations associated with re- experiencing
- Marked cognitive , affective, and behavioral responses
- Intrusive thoughts of the event
- Nightmares and sleep disturbance
- Flashbacks
- Intense psychological and physiological distress when reminded of the event (e.g. severe anxiety)
clinical manifestations associated with avoidance and numbing
- efforts to avoid reminders
- inability to recall important aspects of the event
- withdrawal from favored activities/ interests
- strong feelings of detachment/ or estrangement from others
- restricted range of affect (poker face)
clinical manifestations associated with arousal
- irritability/ outbursts of anger
- difficulty concentrating/ often confused with memory loss
- Hypervigilance
- Exaggerated startle response
Clinician administered PTSD scale for DSM-5 aka CAPS-5
a 30-item, structured interview that can be used to make diagnoses of PTSD in the past week, past month, or lifetime, as well as to assess the severity of PTSD symptoms. There are 3 different versions- for past, week, month and worst month (of lifetime)
First line treatments of PTSD
trauma- focused cognitive behavioral therapy 1st if possible then SSRI’s (most pts will need a combo of the two)
SSRI’s starting doses and therapeutic doses
*Paroxetine 20mg to start, 20- 60mg therapeutic
Sertraline 50mg to start, 50- 200mg therapeutic
Fluvoxamine 50mg to start, 100- 300mg therapeutic
Fluoxetine 20mg to start, 20- 60mg therapeutic
Citalopram 20mg to start, 20- 40mg therapeutic
Escitalopram 10mg to start, 20- 30mg therapeutic
Venlafaxine 37.5mg to start, 37.5- 300mg therapeutic (this is an SNRI)
second line medication tx if SSRI/ SNRI don’t work
they suggest adjunctive treatment with quetiapine or risperidone. (if partial response to SSRI’s to adjunct therapy with these but if no response at all try quetiapine as monotherapy)
For patients started on quetiapine or other SGAs, what do you need to monitor?
regular monitoring of weight gain, blood sugar, and lipids should be conducted
dissociative subtype of PTSD
consists of meeting the full diagnostic criteria for PTSD and, in addition, having depersonalization and/or derealization
Depersonalization
Detachment or estrangement from one’s self;
Derealization
The sense that the external world is strange or unreal
dissociative subtype of PTSD associated with ?
associated with early onset interpersonal trauma
Dissociation is ?
a disruption of the usually integrated functions of consciousness, memory, identify, or awareness of body, self, or environment. Dissociative symptoms can include identity confusion, dissociative amnesia, depersonalization, and derealization
Psychophysiological and neuroimaging studies have found the dissociative and hyperaroused subtypes of response in chronic PTSD to be associated with ?
distinct neural and cardiovascular responses when recalling traumatic memories
Dissociative PTSD patients typically have complex presentations, characterized by a mixture of dissociative and PTSD symptoms embedded with symptoms of other conditions such as ?
depression, substance abuse, somatoform disorders, eating disorders, and self-destructive, impulsive behaviors
Diagnostic criteria for PTSD were revised in DSM-5 to include a subtype, “with dissociative symptoms,” in which PTSD symptoms are accompanied by ?
persistent or recurrent symptoms of depersonalization or derealization
(Shaakira/ kelly article) In military and veteran populations, trials of the first-line trauma-focused interventions CPT and prolonged exposure have shown clinically meaningful improvements for many patients with PTSD. Two principal clinical conclusions can be drawn from this review.
First, the available evidence supports the use of either trauma-focused or structured non–trauma-focused therapies, depending on patient preferences or other factors that might promote treatment retention. Second, there is a need for improvement in existing PTSD treatments as well as the development and testing of novel evidence-based treatment strategies, whether trauma-focused or non–trauma-focused
(Elizabeth article) comparison of accelerated resolution therapy (ART) for tx of sx of PTSD and sexual trauma between civilian and military adults. What is ART?
is an emerging, brief exposure-based therapy for PTSD that has been recently studied in both civilian and military populations
Conclusions of this ART study
In an average of less than 4 treatment sessions, delivery of the ART protocol appears to result in clinically-meaningful reductions in symptoms of PTSD in civilian and military patients with a trend for a potential stronger result in civilians
(Prudence/Josh) Is there a common pathway
to developing ASD (acute stress disorder) and PTSD symptoms?
research suggests that a common path to ASD and PTSD may lie in peri-traumatic responses and cognitions. This study showed that peritraumatic panic, anxiety sensitivity, and negative cognitions about self were significant common risk factors for both ASD severity and PTSD severity when controlled for the effect of the other risk factors. The strongest common risk factor was negative cognitions about self.
(Anne/Alex) A historical review of trauma-related diagnoses to reconsider the heterogeneity of PTSD
basically the diagnosis of PTSD has evolved to include more things over time; world wars, natural disasters, etd. The article calls for more research to determine whether different trauma types are associated with different symptom pre- sentations.
