Responses to Traumatic stress Flashcards
what are centrifugal and centripetal disasters
centrifugal= when individuals are only together at the moment of the disaster (train/ plane crash)
centripetal- affects an existing community (hurricane, tornado, earthquake, flood)
what are type 1 and 2 trauma
type 1 trauma
-single incident, enexpected
type 2 (complex) trauma
- repetitive
- ongion abuse, hostage taking (piracy), genocide
- betrayal of trust in primary care giving relationship
- developmental trauma
- attachment/ attunement disruption
how common is type 2 trauma
may affect as many as 1 in 7 children
which type of trauma is more likely to cause PTSD
type 2
what are the types of traumatic event
individuals exposed:
- intentional (assault, robbery, rape)
- unintentional (RTA, industrial accident)
communities/ populations exposed
- human made (technological, train/ plain crash)
- natural disasters
define a major incident
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
is trauma/ disasters exceptional events
no part of daily life and in some areas/ for some people a repetitive event
who is more likely to be victims (and die) from trauma
poor and marginalised people
is panic a common response to a traumatic event
no most people behave rationally
panic is rare
are survivors of traumatic events left dazed and apathetic
activism is much more common that fatalism
only 15-20% of victims show passive or dazed reactions
after disasters most start reconstruction quickly
what impact can trauma have in later life
chronic depression
bipolar disorder
PTSD
can affect physical health (infections, pain disorders, hypertension, diabetes, asthma, allergies)
what physical health effects is PTSD associated with
increased mortality
chronic cardio, GI (inc liver disease), MSK, endocrine and resp diseases increased
what does anxiety and fear make us do
freeze (distant or inescapable threat)
or to flee (threat nearby and escapable)
what part of brain do decisions such as: Fight, flight, freeze, hide, avoid, attach, submit, despair & uncontrolled activation states
in response to fear originate from
PAG (periaqueductal grey) or ventral tegmental area
what is the purpose of the freeze response to fear
in distant threats: stop, watch, listen- pattern of vigilance
in inescapable threat: tonic immobility occurs (involuntary state of profound, reversible, motor inhibition), especially when direct physical contact with predator/ aggressor
predators less likely to attack immobile prey
if still may loosen grip increasing chances of escape
decreased risk of extreme fighting with fighting back
some attackers loose interest if victim immobile and unresponsive
what response is seen in 1/3-2/3 of all sexual assault causes
tonic immobility
what are the features of tonic immobility
decreased vocalisation intermittent eye contact rigidity and paralysis muscle tremor in extremities chills unresponsiveness in pain
may be associated with peri-traumatic dissociation
what are the types of freeze response
Frozen fight Frozen flight Frozen attach Frozen hide Attentive freeze (broad field) Attention freeze (narrow field) Tonic immobility Low arousal freeze
what are the orienting responses
Arousal -unfamiliar stimulus registers in nervous system
Arrest -pause in or slowing of movement and activity
Alert -all senses heightened (to take in more information)
Muscular change -both flexion & extension
Orient/scan -search for the location (“where is it”)
Locate -source of the stimulus is found
Identify -novelty is recognised &/or identified
Evaluate -what is it? Is it dangerous/friendly? Do I pay attention?
Take action -not dangerous, normal activity resumed
-dangerous- defensive or emergency sequence activated
Reorganise-the nervous system re-equilibrates
what causes the orienting response to vary
the nature of the stimulus: abrupt/ gradual, familiar/ unfamiliar
internal state of the person: existing arousal level, level of consciousness, configuration of mental/ emotional/ physical components
the persons previous experience
-esp past traumatic experience
where in brain is active when dread of capture is felt
periaqueductal gray (PAG)
what does increased proximity to a predator do to brain activity
shifts brain activation from prefrontal cortex to the midbrain Superior Colliculi & periaqueductal gray (PAG)
region responsible for active & passive defence responses
PSTD is associated with a deficiency where
deficiency in top-down modulation of amygdala activation by the prefrontal cortex
what can act as a protective/ resilience factor when exposed to trauma
an ability to regulate emotional responses to negative stimuli
what are the three looping systems of defence activation
First loop – midbrain/brainstem origin
Peri-aqueductal Gray (PAG) & Superior Colliculi (SC)
Second loop – Mesolimbic- Dopamine System
Third loop – Stimulus-response learning system
what can activate the mesolimbic dopamine system (ML-DA)
PAG Inputs:
FEAR
RAGE
PANIC/
Grief
Shame
(dtnorphins, CRF)
CARE/Nurturing
Play/Joy
Sexual Desire
(oxytocin, prolactin, opiods)
what does the acute stress response lead to
dose-dependent increase in catecholamines and cortisol
cortisol acts as to mediate (& shut down) the stress response
through negative feedback it acts on the pituitary, hypothalamus, hippocampus and amygdala
are cortisol levels high or low in PTSD
low
how many people recover from a traumatic event with psychosocial intervention
50%
what are the risk factors for PTSD
in trauma: sudden. unexpected events, man made disaster, prolonged exposure, perceived threat to life, multiple deaths/ mutilation (the grotesque), dose response (proximity), personally relevant factors
patient: severe actute stress reaction, FHx of mental health, physical injury (patients perception), loss of function, extremes of age, genetic predisposition, past trauma experience, coping styles, hopelessness/ powerlessness, personality traits (anxious), aldolescent behavioural problems, lower education/ intelligence/ socioeconomic status, life style, female, substance missuse
environment: lack of support, ongoing life stresses, reactions of others, economic resources, disadvantage, displacement
what are the normal reactions to trauma
numbness, shock, denial fear depression or elation anger, irritability guilt impaired sleep hopelessness, helplessness perceptual changes avoidance intrusive experiences (e.g., flashbacks) hyperarousal, hypervigilance
what are the psychological reactions to trauma
Depression Grief Reactions Panic Attacks +/- agoraphobia Alcohol/Drug Dependence Brief Hypomania Specific Phobias (e.g., travel)
what is commonly comorbid with PTSD
depression, drug and alcohol abuse, and other anxiety disorders
Approximately 80% of patients with PTSD will have >1 co-morbid psychiatric condition
what is the diagnostic criteria for PTSD
traumatic event(s)
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)
duration 1 month
distress and impairment in social or occupational functioning
what are intrusive symptoms
recurrent distressing recollections nightmares flashbacks, in any modality distress accompanies reminders physiological reactions (fight or flight)
what are Avoidant & 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
what are hyperarousal symptoms
sleep disturbance irritability / anger concentration difficulties hypervigilance exaggerated startle response
what are the associated symptoms of ptsd
dissociative symptoms depersonalisation, derealisation, awareness of surroundings near death or out of body experiences survivor guilt performance guilt
what are the features of complex PSTD
PTSD symptoms & Cognitive disturbances- low self-esteem, self-blame, hopelessness, helplessness, pre-occupation with threat Identity disturbance Emotional dysregulation Chronic interpersonal difficulties Dissociation Somatisation Tension reduction activities - binge-purging, self mutilation, substance misuse etc)
what does the limbic system do
emotional and somatosensory memory, attachment
what does the frontal cortex do
Regulatory abilities, cognitive and executive functioning
when in brain for memory
hippocampus
what is bottom up/top down regulation
Processing led by either
Mammalian brain
“top-down” processing
Reptilian brain “bottom-up” processing acting on fear response, physiological mechanisms, can’t orientate to other things, all about escape
what parts of the brain are important in PTSD
Hippocampus
knowledge of its role in declarative or explicit memory & the stress response
Amygdala
role of fear during both trauma & its recollection
what can happen to the size of the hippocampus after trauma
atrophys
what happens to brocas area when individuals access personal traumatic memories
deactivated
what might explain the timeless quality of traumatic memories
right hemispheric lateralisation
what are the general principles for the treatment of PTSD
Ensure safety before starting treatment
management of ongoing trauma (e.g., domestic violence, civil disturbances)
create theraputic relationship
psychological therapy rather than drugs (CBT/ eye movement desensitisation and reprocessing)- should be long, regular and with same therapist
what are the aims of PSTD Tx
normalise reactions enable catharsis inspire hope, restore sense of safety &/or trust treat core symptoms and comorbidity limit kindling of symptoms educate
when should medication for PTSD be considered
Consider symptomatic treatment for acute phase
Consider medication second for augmentation of Trauma-focused psychological treatment for chronic PTSD
Consider issues of patient choice & ongoing threat
is PTSD a stress response
no is an overwhelming of the stress response
