Trauma and PTSD Flashcards
What percentage of the population will experience a significant traumatic event in their lifetime?
Up to 80% of the population will experience a significant traumatic event in their lifetime.
How do most trauma survivors fare in terms of clinical outcomes?
The majority of trauma survivors recover without clinical sequelae.
What percentage of the general population will develop PTSD in their lifetime?
Only 7.8% of the general population will develop PTSD in their lifetime.
What did the SASH study find regarding the 12-month prevalence of PTSD?
The SASH study found the 12-month prevalence of PTSD to be 2.3%.
How do PTSD rates compare in health care providers versus the general population?
PTSD rates are proportionally higher in health care providers.
How is normal anxiety characterized?
Normal anxiety is universally experienced in response to a threat.
How does the DSM-5 define trauma?
Trauma is described in the DSM-5 as the experience or witnessing of an event or events involving actual or threatened death, serious injury, sexual violation, or a threat to the physical integrity of self or others.
Does trauma in the DSM-5 have to evoke intense fear, horror, and helplessness as it did in the DSM-IV?
No, trauma in the DSM-5 does not have to evoke feelings of intense fear, horror, and helplessness as required by the DSM-IV.
How has the classification of mental pathology resulting from traumatic events evolved over time?
The nosology of mental pathology resulting from traumatic events has been refined over time.
How was trauma-related mental pathology classified in DSM-III (1980)?
In DSM-III (1980), it was formerly known as ‘war neurosis’ in soldiers.
How did DSM-IV (1994) classify trauma-related disorders?
DSM-IV (1994) classified them under Anxiety Disorders and included Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD).
How does DSM-5 (2013) classify trauma-related disorders?
DSM-5 (2013) classifies them under Trauma and Stressor-Related Disorders and includes:
- Reactive Attachment Disorder
- Disinhibited Social Engagement Disorder
- Acute Stress Disorder (ASD)
- Post-Traumatic Stress Disorder (PTSD)
-Adjustment Disorders
How long does ASD last after a traumatic event?
ASD is limited to the first 4 weeks after the traumatic event.
How many symptoms and from how many categories are required for an ASD diagnosis?
ASD is characterized by 9 or more of 14 symptoms from five categories.
What are the categories and symptoms for ASD?
- Intrusion Symptoms
- Negative mood
- Dissociation
- Arousal
- Avoidance
Intrusion Symptoms:
- Intrusive memories or repetitive play in children
- Distressing dreams
- Flashbacks as though trauma is recurring
- Intense distress or physiological reaction in response to cues
Negative Mood
Persistent inability to experience happiness, satisfaction, or loving feelings (numbing)
Dissociative Symptoms
Altered sense of reality (depersonalization, derealization)
Dissociative amnesia
Avoidance Symptoms
Avoidance of thoughts or feelings associated with the event
Avoidance of reminders of the event
Arousal Symptoms
- Sleep difficulty
- Irritability and anger
- Hyper-vigilance
- Poor concentration
- Exaggerated startle response
What qualifies as a traumatic event for PTSD?
A traumatic event can be:
- Direct exposure
- Witnessing in person
- Indirectly learning that a relative or close friend was exposed
- Repeated or extreme indirect exposure, usually through professional duties
What are the criteria for re-experiencing in PTSD?
Re-experiencing involves at least one of the following:
- Intrusive recollections or distressing dreams
- Marked distress or physiological reactivity on exposure to cues
- Dissociative reactions (e.g., flashbacks)
What are the criteria for avoidance in PTSD?
Avoidance involves at least one of the following:
Avoiding thoughts, feelings, people, or places linked to the traumatic event
What are the criteria for negative cognitions and mood in PTSD?
Negative cognitions and mood involve at least two of the following:
- Persistent and distorted blame of self or others
- Persistent negative beliefs and expectations of self or the world
- Diminished interest in activities
- Inability to remember key aspects of the event
- Feeling alienated from others
- Persistent inability to experience positive emotions
What is the overarching model used to understand the aetiology of PTSD?
The bio-psycho-social model.
What aspects of the traumatic event influence PTSD?
Factors include:
- Severity of the event
- Onset of symptoms
- Type of traumatic event
What biological factors contribute to the development of PTSD?
- Genetics: Familial patterns have been confirmed.
- Neurochemistry:
- Serotonin: Low levels are associated with mood disturbances and impulsiveness.
- Noradrenaline: High levels are linked to hyperarousal.
- Opiate System: Involvement in emotional numbing.
-Neuroendocrine Factors:
* HPA Axis (Cortisol): Dysregulation can contribute to stress responses
Pre- frontal cortex normal vs PTSD brain
Normal brain: Complex thinking, decision making, and appropriate behaviour
PTSD brain: Dysfunctional thought processing and decision making, inappropriate response to situations
Hypothalamus normal vs PTSD brain
Normal brain: releases hormones like cortisol to help manage and direct efforts to stressor
PTSD brain: overactive, which leads to imbalances in hormones levels and increases stress and anxiety
Hippocampus normal vs PTSD brain
Normal brain: transfers and stores information into memories
OCD brain: stores memories incorrectly and affects memory retrieval
Amygdala normal vs PTSD brain
Normal brain: sets off fight or fight in response to danger
PTSD brain: sets off fight or flight in response to memories or thoughts about danger
Social/ Environmental factors that leads to PTSD
- Protective role of support/validation
- Endemic violence/insecurity
- Role of media
- Natural causes vs. human violence
- Shared “meaning-making” of traumatic experiences
What are pre-trauma predictive factors for the development of PTSD?
Pre-trauma predictive factors include:
- Childhood emotional problems by age 6
- Personal and family history of mental illness (especially depression and other anxiety disorders)
- Previous trauma
- Lower education level
- Lower intelligence
- General childhood adversity
- Female gender
- Younger age at the time of trauma
- Minority racial/ethnic status
What factors during and after trauma can predict the development of PTSD?
Predictive factors during and after trauma include:
- Trauma severity
- Dissociation during or after the trauma
- Lack of social support
- Additional life stressors
- Development of Acute Stress Disorder (ASD)
- Trauma perpetrated by a caregiver
- In military personnel: being a perpetrator, witnessing atrocities, or killing the enemy
What is the common misconception about debriefing in the acute aftermath of trauma?
Debriefing, which involves recall and rehearsing of the traumatic event, is not beneficial and can potentially delay recovery
What are the primary aims of intervention in the acute aftermath of trauma?
The aims of intervention are to:
- Assist with maintaining emotional control
- Restore interpersonal communication
- Help the person return to full functional capacity
Goals of acute stress management : ERASE
E: Reduce Exposure to stress (e.g. secure place)
R:Restore physiological needs (nutrition, pain control)
A: Provide Access to information/ orientation
S: Locate source of Support (relatives, religion)
E: Emphasise Expectation of returning to normal
Why is it important not to force emotional reactions from individuals after trauma?
Forcing emotional reactions can be counterproductive and may hinder the natural recovery process.
What is the current stance on the use of benzodiazepines in the acute aftermath of trauma?
The administration of benzodiazepines to ameliorate distress or as a stress-busting prophylactic measure is no longer recommended. Studies suggest they can worsen outcomes by interfering with the natural recovery process.
Are there any other pharmacological interventions recommended for the prevention of PTSD in the acute aftermath?
Other pharmacological interventions such as atypical antipsychotics, propranolol, and gabapentin have demonstrated no benefit in the prevention of PTSD.
What not to do- 3Ps
- Do not pathologise: Instead rather emphasise that ‘this is a normal response to an abnormal situation’
- Do not psychologise: Do not forcefully facilitate emotional reactions by e.g. group counselling or debriefing. Only provide supportive counselling to those that request it.
- Do not pharmacologise: Do not use benzodiazepines etc. in the first few hours.
Acute stress disorder treatment
‘watchful waiting’ and reassurance recommended in first 4 weeks after trauma.
No evidence for routine use of medication.
Must educate victim and carers about symptoms, when to seek help, as well as what treatments are available.
Aim is to normalize the experience and provide reassurance that only a minority of people will develop PTSD
When to seek help
- Prolonged symptoms more than 4 wks
- Significant impairment in functioning and severe, debilitating symptoms e.g. insomnia
- Symptoms out of keeping- psychosis/ suicidality
PTSD screening
Screen for symptoms using a valid and reliable tool such as the Primary Care PTSD Screen for DSM -5 (PC-PTSD-5)
Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, physical or sexual abuse or assault, seeing someone killed or seriously injured, seeing a loved one die through homicide or suicide.
Have you ever experienced such an event? Y/N (if no then stop, if yes then proceed)
In the past month, have you…
1. Had nightmares about the event(s) or thought about the event when you didn’t want to? Y/N
2. Tried not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Y/N
3. Been constantly on guard, watchful, or easily startled? Y/N
4. Felt numb or detached from people, activities, or your surroundings? Y/N
5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? Y/N
If yes to any three of the five questions then a more detailed assessment for PTSD is warranted
What type of therapies have the best evidence base for treating PTSD?
Trauma-focused cognitive behavior therapies (CBT) have the best evidence base
What are some examples of trauma-focused cognitive behavior therapies for PTSD?
Prolonged Exposure (PE)
Cognitive Processing Therapy (CPT)
Cognitive Therapy for PTSD (CT-PTSD)
Eye Movement Desensitization and Reprocessing (EMDR)
Narrative Exposure Therapy (NET:
How do trauma-focused cognitive behavior therapies differ from generic CBT?
They encompass generic CBT principles and techniques but have a very deliberate focus on the trauma.
What is the current recommendation for trauma-focused cognitive behavior therapies compared to pharmacotherapy?
Trauma-focused cognitive behavior therapies are increasingly recommended as first-line treatments ahead of pharmacotherapy.
What challenges complicate the use of trauma-focused therapies?
Stigma
Lack of expertise
Expense
Willingness to confront trauma
High dropout rates
What are the pharmacological treatments of choice for PTSD?
SSRIs (Selective Serotonin Reuptake Inhibitors) and SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) are the treatments of choice.
Which specific SSRIs and SNRIs have the strongest evidence for PTSD treatment
Evidence is strongest for:
Sertraline
Paroxetine
Fluoxetine
Venlafaxine
How soon can a response to these medications be seen, and how long might it take to see full effects?
A response can be seen as early as 2-4 weeks, but full effects may take up to 12 weeks.
What is the stance on using benzodiazepines for PTSD?
Benzodiazepines are relatively contraindicated for PTSD treatment.
How long do symptoms of PTSD typically last?
Duration of symptoms varies; approximately half of individuals recover completely within 3 months.
Can PTSD symptoms fluctuate over time?
Yes, symptoms may have a waxing and waning course, with reactivation in response to reminders of the trauma.
What is the likelihood of co-morbid conditions with PTSD?
Co-morbidity is more the rule than the exception and may include:
Depression
Substance abuse
Other anxiety disorders
Personality disorders
Bulimia
Impact on clinicians
“Contagiousness” of trauma
Trauma fatigue / burnout
Need for introspection, self reflection
Support - individual or group
Ethical / legal concerns
Conflicts around confidentiality / child protection, military/police etc.
Advocacy role
