Response to traumatic stress Flashcards
What is type 1 trauma?
Single incident trauma, unexpected
What is type 2 trauma?
Repetitive trauma Ongoing abuse, hostage taking, genocide Betrayal of trust in a primary care-giving relationship Developmental trauma Attachment/ attunement disruption
What is the importance of trauma in chronic depression?
A history of early life trauma in chronic depression predicts the need for psychotherapy as an adjunct to pharmacotherapy
What is the importance of trauma in bipolar disorder?
High percentage have a history of childhood deprivation or abuse
What are the impacts of anxiety and fear in a traumatic situation?
Freeze
Flee
All originate in PAG or ventral tegmental area
What is the freeze response?
If distant threat; voluntary
When inescapable threat; tonic immobility occurs which is an involuntary state of profound motor inhibition
In what areas of trauma is the freeze response most common?
Direct physical contact with predator/ aggressor
What is tonic immobility?
Decreased vocalisation Intermittent eye contact Rigidity and paralysis Muscle tremors in extremities Chills Unresponsive to pain
Why does tonic immobility enhance survival?
Predators less likely to attach immobile pain
If attacked, immobility may cause them to loosen grip increasing the changes of escape
Decreased risk of extreme violence which fighting back can cause
Some will lose interest if victim immobile and unresponsive
Very simplified neurobiology of threat?
Increased proximity to a predator shits brain activation from prefrontal cortex to the midbrain superior colliculi and PAG
What is the action of cortisol on the brain?
Acts as a negative feedback on the pituitary, hypothalamus, hippocampus and amygdala
Are cortisol levels high or low in PTSD?
Low
What is the DCM criteria for a traumatic event?
Experiences, witnessed or confronted; induces indirect exposure
Threat of death or serious injury
What is the ICD-10 criteria for a traumatic event?
Delayed or protracted response
Exceptionally life threatening or catastrophic
Likely to cause pervasive distress in almost anyone
What are environmental risk factors for PTSD?
Lack of support network Ongoing life stresses Reactions of others Economic resources Disadvantage Displacement
Normal reactions to trauma?
Numbness, shock, denial Fear Depression or elation Anger, irritability Guilt Impaired sleep Hopelessness, helplessness Perceptual changes Avoidance Intrusive experiences Hyperarousal, hypervigilance
What are common psychological reactions after trauma?
Depression Grief reactions Panic attacks +/- agoraphobia Alcohol/ drug dependence Brief hypomania Specific phobias
What are common co-morbid psychiatric conditions that occur in 80% of patients with PTSD?
Depression
Drug and alcohol abuse
Anxiety disorders
What is intrusive phenomena?
Recurrent distressing recollections Nightmares; particularly in PTSD Flashbacks; visual , auditory, taste, smell, tactile Distress accompanying reminders Physiological reactions (freeze or flee)
What are avoidant and emotional numbing symptoms?
Avoidance of thinking or talking about the event
Avoidance of reminders such as activities, places or people
Amnesia for important aspect of trauma
Loss of interest in activities
Detachment
Emotional numbing
Sense of foreshortened future
Hyperarousal symptoms?
Sleep disturbance Irritability/ anger Concentration difficulties Hypervigilance Exaggerated startle response
What is complex PTSD?
PTSD symptoms along with; Cognitive disturbance; low self-esteem, self-blame, hopelessness, helplessness, preoccupation with threat Identity disturbance Emotional dysregulation Chronic interpersonal difficulties Dissociation Somatisation Tension reduction activities; binge-purging, self mutiation, substance misuse
What is the triune brain theory?
Mammalian brain (or limbic system): emotional and somatosensory memory, attachment Frontal cortex: regulatory activities, cognitive and executive function Reptilian brain; autonomic arousal, instinctive responses
Which areas of the brain are of interest in PTSD?
Hippocampus (role in memory and stress response)
Amygdala (role of fear both ni trauma and itr recollection)
What is the correlation between the hippocampus and PTSD?
Size of hippocampus correlates with the severity of PTSD
What conditions are low hippocampal volume associated with?
Bipolar disorder Aging preceding dementia Dementia Cushing's syndrome Alcohol misuse Borderline personality disorder
Summary of the neurobiology behind fear and PTSD?
Under threat; activity shifts to PAG Hippocampal atrophy Increased activity of amygdala and other limbic activities Deactivation of broca's area Right-hemispheric lateralisation
What is the aim of treatment in PTSD?
Normalise reactions Enable catharsis Inspire hope, restore sense of safety +/- trust Treat core symptoms and comorbidity Limit kindling of symptoms Educate
Which psychological therapies have been shown to have an effect in PTSD?
CBT
EMDR (Eye Movement Desensitisation and Reprocessing)
How many sessions are recommended for PTSD?
12
Which medications are recommended as a 2nd line in PTSD treatment?
Paroxetine Citalopram Mirtazapine Prazosin (nightmares) Mood stabilisers Risperidone
