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Psychiatry > Responses to Trauma > Flashcards

Responses to Trauma Flashcards

1
Q

Trauma can be either?

A

Intentional or Unintentional

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2
Q

Give 3 examples of intentional trauma.

A
  • Assult
  • Robery
  • Rape
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3
Q

Give 2 examples of unintentional trauma.

A
  • RTA

* Industrial accident

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4
Q

In the context of a disaster, what is meant by ‘centrifugal’?

A

People are together only at the moment of the accident e.g plane crash

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5
Q

In the context of a disaster, what is meant by ‘centripetal’?

A

An existing community e.g hurricane, earthquake, tornado, flood

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6
Q

What is type 1 trauma?

A

A single incident trauma, unexpected

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7
Q

What is type 2 trauma?

A

Complex trauma

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8
Q

Type 2 trauma is _________

A

REPETITIVE

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9
Q

Give 3 examples of type 2 trauma.

A
  • Ongoing abuse
  • Hostage taking (piracy)
  • Genocide
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10
Q

How many people are affected by type 2 trauma?

A

1 in 10 adults

1 in 7 children

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11
Q

How much higher is the risk of PTSD in people with type 2 trauma compared to type 1 trauma?

A

3x

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12
Q

“Any situation associated with multiple casualties and fatalities, and damage to property, due to natural or unnatural causes, that is beyond what can be coped with ordinarily by the deployment of the emergency services” this is the definition of?

A

A major accident

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13
Q

Is panic rare or common in trauma?

A

Surprisingly it is rare

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14
Q

Activism is much more common than fatalism in a traumatic event

A

TRUE

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15
Q

In patients with chronic depression, what predicts the need for psychotherapy as well as pharmacotherapy?

A

A history of early life trauma

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16
Q

What do a high percentage of patients with bipolar disorder have?

A

Childhood deprivation or abuse

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17
Q

In what ways does PTSD often affect physical health?

A
  • Excess all-cause mortality.
  • Chronic diseases such as cardiovascular, digestive (incl. liver disease), MSK, endocrine, resp
  • Stands up even when control for other factors (incl alcohol and drugs)
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18
Q

What 2 things are genetically ingrained functions of the NS?

A

Anxiety and fear

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19
Q

Anxiety and fear arise from neural processes that prompt us to do what?

A

FREEZE or FLEE

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20
Q

What do people FREEZE in response to?

A

Distant or inescapable threat

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21
Q

What do people FLEE in response to?

A

Threat which is nearby and escapable

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22
Q

Where does fight or flee originate?

A

In the PAG or Ventral Tegmental Area

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23
Q

What occurs in inescapable threat?

A

Tonic immobility

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24
Q

What is tonic immobility?

A

An involuntary state of profound (but reversible) motor inhibition

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25
Q

When, especially, does tonic immobility occur?

A

There is direct physical contact with predator/aggressor.

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26
Q

What type of case does tonic immobility often occur in’?

A

Sexual assault cases

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27
Q

Outline some features of tonic immobility.

A
  • Decreased vocalisation.
  • Intermittent EC.
  • Rigidity and paralysis.
  • Muscle tremors and extremities.
  • Chills.
  • Unresponsive to pain.
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28
Q

What may tonic immobility be associated with?

A

Peri-traumatic dissociation

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29
Q

What is the benefit of tonic immobility?

A

It enhances survival

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30
Q

How does tonic immobility enhance survival?

A
  • predators less likely to attack immobile prey.
  • if attack, immobility may cause them to loosen grip, increasing chances of escape.
  • decreased risk of extreme violence which fighting back can cause.
  • some attackers lose interest if victim is immobile and unresponsive.
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31
Q

What does the orientating response vary according to?

A
  • Nature of the stimulus
  • Internal state of the person
  • The persons previous experience
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32
Q

What happens in the brain as a predator gets closer?

A

Brain activity shifts from the ventromedial prefrontal cortex to the periaqueductal grey

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33
Q

It has been suggested that PTSD is due to a deficiency of ?

A

The top-down modulation of amygdala activation in the prefrontal cortex
The ability to regulate emotional responses to negative stimuli may be a PROTECTIVE FACTOR when exposed to trauma – a RESILIENCE FACTOR

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34
Q

What is defence activation composed of?

A

3 looping systems

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35
Q

Name the 3 loops in defence activation?

A
  1. Midbrain/brainstem origin - peri-aqueductal gray (PAG) and superior colliculi (SC)
  2. Mesolimbic-dopamine system
  3. Mesolimbic-dopamine system
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36
Q

What does acute stress lead to a dose dependant increase in?

A

Catecholamines and cortisol

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37
Q

What does cortisol act to mediate and shut down?

A

The stress response

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38
Q

How does cortisol work?

A

Through negative feedback, this acts on the pituitary, hypothalamus, hippocampus and amygdala.
These sites are responsible for the stimulation of cortisol release.
Acute stress therefore increases cortisol release.

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39
Q

What is the biological paradox of cortisol?

A

CORTISOL LEVELS ARE LOW IN PTSD

40
Q

In what condition, are cortisol levels low?

A

PTSD

41
Q

What does acute stress do to cortisol levels?

A

INCREASES it

42
Q

According to DSM, what is required for something to be described as a ‘traumatic event’?

A
  • Experienced, witnessed or confronted
  • Threat of death or serious injury (self or others)
  • [intense fear, helplessness or horror]
43
Q

According to ICD, what is required for something to be described a ‘traumatic event’?

A
  • delayed &/or protracted response
  • exceptionally threatening or catastrophic
  • likely to cause pervasive distress in almost anyone
44
Q

For both DSM and ICD, what is a traumatic event?

A

The primary and overriding casual factor

45
Q

What are the 3 categories of pre-traumatic risk factors?

A
  • Personal capabilities and attributes.
  • Past personal experiences.
  • Environment.
46
Q

List some personal capabilities and attributes.

A
  • Attachment capacity.
  • Current attachments.
  • Locus of control (ie. in charge of own destiny compared with feeling reliant on others).
  • Gender (males cope better).
  • Extremes of age and development (children and older people).
  • Behavioural problems (<15yrs).
47
Q

List some past personal experiences which act asa a risk factor for pre-traumatic events.

A
  • Childhood experience of trauma (can be + or -)
  • Substance misuse
  • Previous psychiatric history
  • (Dis)advantage (social, educational or economic)
48
Q

List some environmental factors which can predispose someone to pre-traumatic events.

A
  • Concurrent life stressors or strengths.

* Social capital.

49
Q

List some normal signs and symptoms of trauma

A
  • numbness, shock, denial
  • fear
  • depression or elation
  • anger, irritability
  • guilt
  • impaired sleep
  • hopelessness, helplessness
  • perceptual changes
  • avoidance
  • intrusive experiences (e.g flashbacks)
  • hyperarousal, hypervigilance
50
Q

What is agoraphobia?

A

Feeling like your environment is unsafe and you cannot escape

51
Q

List some physiological reactions after trauma.

A
  • Depression
  • Grief Reactions
  • Panic Attacks +/- agoraphobia
  • Alcohol/Drug Dependence
  • Brief Hypomania
  • Specific Phobias (e.g., travel)
  • PTSD
52
Q

What type of trauma causes the most PTSD?

A

Rape and sexual assault

53
Q

Is there a risk between PTSD and suicide?

A

Yes – PTSD has a stronger association with suicide than any other anxiety disorder

54
Q

By how much is the risk of suicide increased in those with PTSD compared to controls?

A

6x

55
Q

What do ~60% of men, and 40% of women with PTSD meet criteria for?

A

Greater than or equal to 3 other psychiatric diagnoses

56
Q

Approximately 80% of patients with PTSD will have at least one co-morbid psychiatric condition. What are the most common of these?

A

Depression
Drug/alcohol abuse
Anxiety disorder

57
Q

Describe the burden of PTSD on patients.

A

Severe impairment of social functioning, resulting in unemployment and relationship problems

58
Q

Rates of PTSD rise with age in….

A

MEN, but not women

59
Q

How much more common is PTSD in women?

A

2.5x

60
Q

Outline the DSM IV criteria for PTSD.

A
  • traumatic event(s)
  • intrusive symptoms: 1 or more
  • avoidance symptoms: 3 or more
  • increased arousal: 2 or more
  • duration 1 month
  • distress and impairment in social or occupational functioning
  • acute / chronic / delayed onset
61
Q

Give examples of intrusive phenomenon.

A
  • Recurrent distressing recollections.
  • Nightmares.
  • Flashbacks, in any modality.
  • Distress accompanies reminders.
  • Physiological reactions (fight or flight).
62
Q

Outline avoidance and emotional numbing symptoms.

A
  • 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
63
Q

Outline hyperarousal symptoms.

A
  • sleep disturbance
  • irritability / anger
  • concentration difficulties
  • hypervigilance
  • exaggerated startle response
64
Q

Outline the DSM V criteria for PTSD.

A
  • traumatic event(s) – no longer need emotional response at time of trauma (now criterion D)
  • intrusive symptoms: 1 or more (of 5)
  • avoidance symptoms: 1 or both (…of 2)
  • negative alterations in cognitions & mood 1 or more (of 7)
  • increased arousal & reactivity: 2 or more (of 6)
  • specify whether with dissociative symptoms
  • duration 1 month
  • distress and impairment in social or occupational functioning
65
Q

What is criterion D for DSM V criteria for PTSD?

A

Negative alterations in cognitions and mood, associated with the traumatic event(s), beginning or worsening after the TE.

66
Q

Give 2 examples of criterion D for DSM V criteria for PTSD?

A
  • Persistent & exaggerated negative beliefs or expectations about oneself, others or the world (e.g., I am bad; the world is completely dangerous)
  • Persistent, distorted cognitions about the cause or consequences of the TE(s) that lead the individual to blame himself/herself or others

Persistent negative emotional state (e.g fear, horror, anger, guilt or shame)

67
Q

What is criterion E for PTSD in DSM V?

A

Marked alterations in arousal and reactivity associated with the TE . . .reckless or self-destructive behaviour

68
Q

TE

A

traumatic event

69
Q

Where are defence and orienting responses, like basic emotional systems, generated?

A

In the midbrain

70
Q

What is the brainstem, including the midbrain, the major influencer of?

A

The autonomic nervous system

71
Q

What type of processing is the mammalian brain responsible for?

A

‘Top-down’

72
Q

What type of processing is the reptilian brain responsible for?

A

‘Down-up’

73
Q

What does the hippocampus have a role in?

A

Declarative or explicit memory, and the stress response

74
Q

What does the amygdala have a role in?

A

Fear, both during the trauma and its recollection

75
Q

Where do changes to the hippocampus appear in adult trauma?

A

RIGHT

76
Q

Where do changes to the hippocampus appear in childhood trauma?

A

LEFT

77
Q

There is an apparent paradox at the heart of neurobiological and imaging studies in PTSD. What is this?

A

High cortisol levels damage the hippocampus BUT cortisol levels are low in PTSD

78
Q

Suggest an explanation from why there is high cortisol levels in acute stress but low in PTSD?

A

Receptors for cortisol are more sensitive in people with PTSD – at the level of the pituitary gland

79
Q

What condition is decreased hippocampal volume associated with?

A

Bipolar disorder

80
Q

What area of the brain gives people such vivid memories of traumatic events in that ‘it feels like yesterday’?

A

Brocca’s area

81
Q

Impairment of what is related to amygdala damage?

A

Emotional event memory

82
Q

In what condition will damage to amygdala be seen?

A

Alzheimers

83
Q

When a person is under threat, what shifts in brain activity occur?

A

Activity shifts to PAG

84
Q

What happens to the brain when someone accesses personal traumatic memories?

A

Deactivation of Brocca’s area occurs

85
Q

What may explain the ‘timeless’ quality of traumatic memory?

A

Right hemispheric lateralisation

86
Q

What are 2 trauma focussed treatments?

A
  • CBT

* EMDR

87
Q

What type of approach is generally accepted for the treatment of complex PTSD?

A

A phased approach.

although evidence base is not strong

88
Q

Outline the structure of a phase approach in the treatment of complex PTSD.

A
  • Stabilisation and resourcing (incl ‘safety’).
  • Reprocessing of trauma memories/material.
  • Reintegration.
89
Q

When should medication be considered in PTSD?

A

In the acute stage if patients are symptomatic

90
Q

Give examples of medications for PTSD that non specialists can prescribe.

A
  • Paroxetine

* Mirtazapine

91
Q

Give examples of medications that specialists can prescribe for PTSD.

A
  • Amitriptyline

* Phenelzine

92
Q

Suggest alternative medications that can be used in the treatment of PTSD.

A

Prazosin, atypical antipsychotics or mood stabilizers (carbamazepine).

93
Q

PTSD is NOT…..

A

A normal adaptation to severe, traumatic stress
A normal response to trauma
The inevitable response to trauma

94
Q

Most trauma exposed patients do NOT develop PTSD

A

TRUE

95
Q

Outline the psychological treatment for PTSD.

A

– CBT / EMDR for single event PTSD / more straightforward presentations
– neither are sufficient for complex PTSD
– sadly, guidelines don’t always guide

96
Q

‘Disasters’ can be?

A

Individual or collective

97
Q

Many people can recover quickly from PTSD or only have brief stress

A

TRUE

Psychiatry (31 decks)

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