Reaction to a stressful or traumatic event

Question 1

What is derealisiation

Answer 1

A perception that the environment is somehow different or strange, although the individual cannot account for the changes

Question 2

What is dissociative amnesia

Answer 2

Memory loss of some component of an event

Question 3

What is a psychosocial stressor

Answer 3

Any life event, condition or circumstance that places a strain on a person’s current coping skills.

Question 4

How does traumatic stress differ from psychosocial stress

Answer 4

Traumatic stressor is outside the range of normal human experience, considered stressful for most people. However psychosocial stressor in person dependant.

Question 5

The propensity to develop a stress reaction depends on two broad categories

Answer 5

Nature and severity of event

Nature and severity of person’s reaction

Question 6

Possible mental health disorders that can arise from stressful/traumatic experience

Answer 6

(1) an adjustment disorder
(2) an acute stress reaction or
post-traumatic stress disorder (PTSD)
(3) a dissociative
disorder
(4) another major mental illness such as a depressive, anxiety or psychotic disorder, substance use disorder

Question 7

Adjustment disorder- diagnostic criteria

Answer 7

A) The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B) These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

–>Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.

–>Significant impairment in social, occupational, or other important areas of functioning.

C) The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.

D) The symptoms do not represent normal bereavement.

E) Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

Question 8

Diagnostic criteria acute stress reaction

Answer 8

A) Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:

–>Directly experiencing the traumatic event(s).

–>Witnessing, in person, the event(s) as it occurred to others.

–>Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

–>Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).

B) Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion Symptoms

• ->Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
• ->Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.
• ->Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
• ->Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Negative Mood
–>Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Dissociative Symptoms

• ->An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
• ->Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Avoidance Symptoms

• ->Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• ->Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Arousal Symptoms

• ->Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
• ->Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.

Hypervigilance.

• ->Problems with concentration.
• ->Exaggerated startle response.

Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.

C) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D) The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder

Question 9

Overview of PTSD criteria

Answer 9

A) Exposure
B) Intrusive->memories, dreams, flashbacks, prolonged distress/physiological response to cues re to stressor
C) Avoidance->of thoughts and places/reminders
D) Cognition->memory, negative beliefs about self, blame, negative emotional state, lack interest, detachment, cannot experience positive emotion
E) +Arousal-> irritable, Hypervigilance, reckless, +Startle, concentration, sleep
F) >1 month
G) Significant impairment
H) Not due to something else

Question 10

Pathogenesis of PTSD

Answer 10

1. PTSD represents a failure of the medial prefrontal-anterior cingulate networks to regulate amygdala activity, resulting in hyper-reactivity to threat.
2. Fearful situations lead to production of cortisol through a loop involving the amygdala, hypothalamus, and anterior pituitary gland.
3. Optimal cortisol levels reduce the risk of developing and maintaining PTSD by inhibiting traumatic memory retrieval and containing the sympathetic response.
4. There is evidence that in PTSD, lower than normal levels of cortisol inhibit production of ACTH from the anterior pituitary gland.
5. In addition, there is evidence of down-regulated sensitivity to corticotrophin-releasing-factor (CRF) resulting in suboptimal levels of cortisol.
6. The elevated CRF levels directly influence increased norepinephrine (noradrenaline) release by stimulating the locus coeruleus: it is believed that this failure to contain the sympathetic response leads to the consolidation of traumatic memories

Question 11

Management of PTSD

Answer 11

1. Pharmacotherapy
2. Psychotherapy
3. Social interventions: food, housing, clothing, safety/security

a. Mild-moderate, watchful waiting. Family/community support
b. Severe/>3 months->trauma focused CBT, fluoxetine/paroxetine/venlafaxine, a2 agonists (prazocin) for minimum of 12 months, eye movement and reprocessing therapy. Can also consider non- trauma focused CBT

Question 12

Prognosis

Answer 12

Average duration if treated is 36 months, if untreated 64 months.
50% experience symptom reduction, 30% never fully recover

Question 13

Risk factors

Answer 13

Female
Previous psychiatric illness
Lowed educational
Lower SES

Question 14

Differential

Answer 14

Need to determine if co-existing
Depression
Anxiety
Substance