TASK 2 - PTSD Flashcards
PTSD
= post-traumatic stress disorder
- consequences of experiencing extreme stressors
- 1980 named; before different names in wars
DSM-5 criteria
A.
exposure to actual/ threatened death, serious injury or sexual violence in one (or more) of the following ways
- directly experiencing
- witnessing, in person, the event occurring to others
- learning that it occurred to close others
- experiencing repeated/ extreme exposure to aversive details of a traumatic event (e.g. first responders collecting human remains)
- trauma
DSM-5
B.
presence of one (or more) of the following symptoms beginning after the traumatic event occurred
- recurrent, involuntary, intrusive distressing memories
- distressing dreams/nightmares (content and/or affect are related to trauma)
- dissociative reactions (flashbacks) in which person feels/ acts as the event was recurring
- intense/prolonged psychological distress at exposure to internal/external cues that symbolise/resemble an aspect of event (triggers)
- marked psychological reactions to internal/external cues that symbolise/resemble an aspect of the event
DSM-5
C.
persistent avoidance of stimuli associated with the traumatic event, beginning after the event occurred, evidenced by one or both …
- avoidance of distressing memories/thoughts/ feelings about the event (internal)
- avoidance of external reminders
- avoidance of stimuli
DSM-5
D.
negative alterations in cognition + mood associated with the traumatic event, beginning/ worsening after it occurred as evidenced by two (or more) of the following
- inability to remember an important aspect due to dissociative amnesia
- persistent, exaggerated negative beliefs + expectations
- persistent, distorted cognitions about the cause/ consequences –> leads individual to blame him/herself or others
- persistent negative emotional state (depression)
- diminished interest/ participation in significant activities
- feeling of detachment/ estrangement from others
- persistent inability to experience positive emotions
- negative changes
DSM-5
E.
marked alterations in arousal + reactivity associated with the traumatic event beginning/ worsening after it occurred as evidenced by two (or more) of the following
- irritable behaviour, angry outbursts
- reckless/destructive behaviour
- hypervigilance
- exaggerated startle response
- problems with concentration
- sleep disturbance
- changes in arousal/reactivity
DSM-5
F.
duration of the disturbance (B, C, D, E) is more than one month
- duration
DSM-5
G.
disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning
- impairment
DSM-5
H.
disturbance isn’t attributable to the effects of substances or another medical condition
- medical exclusion
main symptoms (B) - reexperiencing trauma
- recurring nightmares, flashbacks in which they relive the event
- when something reminds of the event
- relives emotional
- chronically experiences negative emotions
main symptoms (B) - emotional numbing
- persistent avoidance of stimuli associated with trauma
- become withdrawn, feel numb
- feel detached from themselves and ongoing experiences –> especially after trauma
- sense of foreshortened future: not expecting to reach typical milestones in life
main symptoms (B) - chronic arousal
- always on guard for trauma to reoccur
- perceptions that remind them of trauma, instantly create panic
- survivor guilt
subtypes
- acute stress disorder
= similar to PTSD but more short-term
- consequence of experiencing extreme stressors; response to traumas similar to those involved in PTSD
- symptoms arise within 1 month of exposure to stressor and last no longer than 4 weeks
- flashbacks, avoidance, chronic arousal
- dissociative symptoms are common (numbing, detachment, depersonalisation)
- short-term response to trauma –> high risk of PTSD
subtypes
- adjustment disorder
= emotional and behavioural symptoms (depressive, anxiety symptoms +/ antisocial behaviours)
- symptoms arise within 3 months of experience of stressor; can be of any severity
- people who experience emotional, behavioural symptoms following stressor –> do not meet criteria for PTSD, acute stress, anxiety/mood disorder
subtypes
- dissociation
= process in which different facets of one’s sense of self (memories/consciousness) become disconnected from one another
- in addition to meeting criteria of PTSD experience following symptoms to stressor:
1. depersonalisation: persistently feeling detached from, and as if one were an outside observer of one’s mental processes or body
2. derealisation: persistent experience of unreality of surroundings
subtypes
- delayed expression
if full diagnostic criteria are not met until 6 months after the event
prevalence
- most gradually have less symptoms
- co-morbidities: >50% (often mood, anxiety, sleep substance-related, personality disorder)
trauma type and prevalence
grosso modo = dose-response relationship
- the more extreme/often the trauma, the higher the risk to develop PTSD
- interpersonal violence (abuse) especially
risk factors
- BEFORE (vulnerability)
- genetic vulnerability
- gender (female)
- age (young)
- intelligence (low)
- socio-economic status (low)
- psychopathology
BEFORE
- biological factors
- differences in brain areas that regulate emotion, fight-or-flight response, memory (= amygdala, hippocampus, prefrontal cortex)
- stronger amygdala: more reactive to emotional stimuli
- weaker medial PFC: less able to dampen reactivity in stress response
- smaller hippocampus: memory problems –> due to overexposure to neurotransmitters/hormones in stress response
- -> problems with regulation of the body’s fear response (doesn’t return back to normal after threat has passed)
BEFORE
- biochemical factors
- lower resting cortisol levels: (NOT elevated stress response) –> prolonged activity following stress –> more easily develop conditioned fear of stimuli –> PTSD
- exaggerated heart rate
- icreased secretion of epinephrine/ norepinephrine
- different components of stress response may not be working in sync
1. HPA (hypothalamic-pituitary-adrenal) axis: unable to shut down response of sympathetic NS by secreting necessary levels of cortisol
2. overexposure of brain to epinephrine, norepinephrine
3. memories of traumatic over-consolidated - childhood trauma: permanently alter biological stress response (more vulnerable) –> abnormal cortisol responses to stressors as adults
BEFORE
- gender/cultural factors
- women: greater likelihood
1) may experience some triggers more often (anxiety disorders)
2) may receive less social support (experienced traumas are more stigmatised (sexual abuse)) - minorities are less likely to seek treatment
- strength of traditional sex roles:
- -> greater sex differences (women = passive, men = strong)
BEFORE
- social/environmental factors
- available social support: people with emotional support recover more quickly after trauma
BEFORE
- psychological factors
- general increased symptoms of anxiety/ depression prior to experience
- coping style
a) self-destructive/avoidant strategies (e.g. drinking/ self-isolation)
b) dissociation shortly after trauma
risk factors
- DURING (trauma)
- experienced threat/proximity (direct, indirect)
- type of trauma
- duration of trauma
- severity of harm
- -> more sever, longer-lasting traumas, more directly affected by trauma
DURING
- trauma type (A)
- involuntary act
- natural disasters (floods, tsunamis)
- human made disasters (wars, terrorist attacks, torture) –> soldiers + citizens
- abuse (physical = domestic violence, sexual = rape, incest)
- -> one most commonly associated with PTSD (46% of victims develop PTSD)
risk factors
- AFTER (effect)
- negative interpretation of symptoms + consequences of trauma
- low social support
- -> secondary trauma (blaming, slut-shaming)
- changes/new life events
- anger/guilt/shame
- dissociation
theories
- emotion-based vs. intrusion-based reasoning
- tend to prioritise the processing of threatening information + attend selectively to trauma-related information
- related to severity, not to actual exposure
- becomes self-perpetuating when initial symptoms are processed in a way that produces a sense of current threat –> amplifies distress & avoidance strategies
- -> importance of negative appraisals of initial symptoms in maintaining disease
emotion-based reasoning (ER)
(phobias, anxiety disorder)
= infer danger from own anxious responses
- interpret anxiety responses themselves as evidence that threat is impending –> instead of inferring dangers only from objective information
- if anxiety, then threat
- negative appraisals of initial PTSD might incite sense of current threat –> fosters symptom persistence –> strongly linked to chronic PTSD
- internal threat (“I’m going crazy”) or external (“the world is dangerous”)
intrusion-based reasoning (IR)
= inferring danger from distressing intrusions
- interpret distressing intrusions themselves as evidence that danger is impending –> instead of inferring dangers from objective information
- if intrusions, then threat
- associated with lower intelligence –> fewer cognitive resources = worse coping with PTSD symptoms, more vulnerable
ER vs. IR
- vietnam veterans
- no PTSD: inferred danger from objective information
- yes PTSD: inferred danger from intrusion (IR) & anxiety responses unrelated to PTSD (ER)
- have difficulty supressing meaning of trauma-related words once activated
- interpret anxiety responses & PTSD-intrusions themselves as indicator of threat
- adjust for perceptions of uncontrollability –> effects are reduced
ER vs. IR
- train disaster
- predictors for PTSD
- -> whether individuals interpret symptoms themselves negatively
- -> whether they interpret situation differently based on the presence of intrusion
- intrusions may serve as contextual cues –> different stimulus predicts harm
- when having more intrusions about train disaster, the situation is held to be more dangerous relative to the absence of intrusion
contribution of ER + IR to PTSD persistence
- common experience of intrusions & anxiety are taken as evidence that doom is impending and the world is unsafe
- fosters avoidance of cues that lead to the experience of anxiety
- amplify distress –> increases frequency of intrusive thoughts
- motivate people to search actively for danger-confirming information (confirmation bias)
- -> predicts PTSD (2. experiment)
theories
- memory (WM)
- memory of event ≠ actual event
- -> can be false memories after time (after a lot of recall)
- memory of trauma = unconditioned stimulus leading to a conditioned response
1. recall
2. memory becomes labile
3. while in WM memory can be changed
4. changes influence storage in LTM
dissociative disorder
= subtype; wide variety of syndromes with common core; alteration in consciousness that affects memory and identity
- “functional” in nature: not a result of injury or disease affecting the brain
dissociative disorder subtypes
1. dissociative amnesia
= loss of autobiographical memory for certain past experiences (7%)
dissociative disorder subtypes
2. dissociative fugue
- dissociative fugue = loss of awareness of one’s identity, flight from one’s typical environment
- amnesia covers large part of the patient’s life
- accompanied by loss of personal identity; in many cases physical relocation
dissociative amnesia
- amnesia in fugue states is retrograde (= for events pre-onset of fugue state)
- after fugue: memory of premorbid events is restored
- during fugue state: general semantic knowledge is preserved –> except that for identity
- amnesias are reversible = not encoding but retrieval problem
dissociative disorder subtypes
3. dissociative identity disorder (DID)
= single patient appears to have 2 or more distinct identities (alter egos)
- alternate in control over conscious experience; typically are separated by some degree of amnesia (1,3%)
- treatment: focused on assumption that it’s caused by childhood trauma; integration of alter egos into a single identity (success rate 9-22% but can actually increase symptoms)
dissociative amnesia
- inter-personality amnesia
= one alter ego doesn’t know what another did
BUT implicit memories sometimes transfer between personalities (depends on nature of the test)
–> autobiographical memory depends on alter ego
- symmetrical pattern: two alter egos unaware of each other
- asymmetrical pattern: one aware, the other not
- amnesias are reversible = not encoding but retrieval problem
dissociative disorder subtypes
4. depersonalisation disorder (DPD)
= patients believe they have changed in some way or are in some way no longer real
- commonly observed in acute stress reactions
- hypothesis: dysregulation along the hypothalamic-pituitary adrenal axis
- treatment: sometimes successful with anxiolytic or antidepressant drugs (could be primary or secondary effect)
dissociative disorder subtypes
5. dissociative disorders NOS
= have some symptoms but not to the extent that qualifies for one of the major diagnoses (subclinical)
dissociative disorder
- diagnosis
- very subjective due to ambiguous definition of identity, personality + amnesia
- SCID/ SCID-D
- DES
dissociative disorder theories
- trauma-memory argument
= psychological defences (repression or dissociation) to block awareness of trauma –> amnesia caused by trauma stress itself or the defences against it
- develop different identities (dissociation) to cope with trauma
- traumatic stress interferes with consolidation of narrative memory BUT enhances nonverbal, sensory, motor representations of trauma
BUT often victims remember things all too vividly & forgetting can be explained by normal memory processes
- DID mostly attributed to extreme trauma –> no proper evidence
dissociative disorder theories
- revised trauma-memory argument
(special note of trauma associated with incest/childhood sexual abuse)
= memory is enhanced for terror traumas (= combat), impaired (by dissociation) for betrayal traumas (= incest)
1. type I traumas (= simple, well-defined events) = memory enhanced
2. type II trauma (= repeated over extended period of time) = psychic numbing & dissociation
dissociative disorder
- forensic implications
- amnesic cannot assist in their own defence, cannot offer testimony to what they’ve witnessed –> raises possibility of malingering
- DID syndrome raises question about personhood and personal responsibility of alter ego
treatment
- CBT
- trauma-focused psychotherapy
- systematic desensitisation = expose clients to what they fear in order to extinguish that fear
1. identify thoughts, situations that create anxiety - safe environment: allows to habituate to anxiety + distinguish memory from reality
2. rank them from most anxiety-provoking to least
3. take client through hierarchy - use relaxation techniques, watch for unhelpful thinking patterns (survivor guilt)
- challenge distorted cognition
- stress management interventions = teach client skills to overcome problems in lives that increase stress, may result from PTSD (marital problems, social isolation)
√ effective
treatment
- biological/medication
- selective serotonin re-uptake inhibitors (SSRIs) (+ benzodiazepines to lesser extent)
- treating symptoms like sleep problems, nightmares + irritability
x evidence for effectiveness is mixed
treatment
- EMDR
= recalling traumatic memories while simultaneously making horizontal eye movements
- eye movements decrease vividness & emotionality of memory –> have an effect
1. two tasks compete for limited WM capacity
2. eye movements require WM –> less capacity for memory
3. recall (makes reconsolidation more labile) + reconsolidation is less vivid, emotional
- imagination deflation effect = imagination deflation affects the next recall
- counter-effective with positive memories –> become less pleasant
- moderate difficulty level for task is best (= inverted U): too little/much have little or no effect
- low WM capacity (= more easily distracted) benefit more from eye
–> any task that actually taxes WM
- effective treatment for alleviating trauma symptoms
√ flashbacks + flash-forwards (= disturbing images about possible future events) become less vivid and emotional
treatment
- mindfulness-based cognitive therapy (MBCT)
= mindful breathing (= eye movement) = focus on breathing —> accept thoughts that appear –> slowly draw attention back to breathing
- deep breathing calms physically + psychologically
- effective in preventing relapse after treatment for depression
√ same effects as EMDR
√ almost the same degree as eye movements
treatment
- EMDR + beeping
NOT effective: beeps do not tax WM –> registering is a passive task (= need to actually do something)
treatment
- dissociative disorder
- presence of DS doesn’t moderate the outcome of trauma-focused treatments
- amount of improvement is same for those with/ without
- psychodynamic, insight-oriented psychotherapy: focus on uncovering, working through trauma underlying disorder + getting patient to abandon dissociative defences
