Trauma and PTSD Flashcards
Define PTSD and list the main cluster of symptoms
[for 4 weeks]
Experience of a severe traumatic event of an exceptionally threatening nature, which is likely to cause distress in almost anyone
Main Symptoms:
- re-experiencing (re-living)
- hyperarousal
- avoidance
Examples of re-experiencing (re-living)
- “flashbacks”
- recurring memories associ w/ traumatic event
- recurring dreams of event
Examples of hyperarousal
- difficulty falling asleep
- irritability and outbursts of anger
- concentration difficulties
- exaggerated startle response (noise/fireworks}
Examples of avoidance
- efforts to avoid thoughts, feelings assoc w/ trauma
- efforts to avoid activities, places, ppl that arouse trauma recollections
- feeling detached (from others)
- reduced interest in participating in important activities
DSM-V: four factor model for negative alterations in cognition and mood:?
- persistent negative cognitions about self, others, world
- persistent negative emotional states
- diminished interest in significant activities
- inability to experience positive emotions
Examples of of trauma
- combat trauma
- torture
- rape
- terrorism
- witnessing violent deaths (e.g. war)
How to categorise trauma?
- Type I: single traumatic event
- Type II: prolonged and repeated trauma
- Interpersonal vs natural disaster
- intergenerational trauma
- concept of catastrophic trauma
Aetiology of PTSD?
[unclear why others develop and others don’t]
Correlations of PTSD aetiology in the literature
- heritability 30%- Goldberg et al 1990
- impaired HPA axis sensitivitity- Yehuda et al, 1991
- reduced hippocampal volume
Prevalence of PTSD
- 8% of general population (Kessler et al, 1995)
- 14% in general practice (Gomez-Beneyto et al, 2006)
- 31% of Vietnman war veterans had lifetime PTSD (Kulka et al, 1990)
NB: PTSD more prevalent in victims of interpersonal trauma rather than disaster victims
Relevance of comorbidities in PTSD?
- Alcohol abuse: M-52%,F-27% (Kessler et al, 1995)
- Drug misuse (34%)
- MDD (48%)
- physical health problems (e.g. stomach ulcer) more prevalent than general population
Treatment for PTSD?
- watchful waiting if mild/moderate (for first 4 weeks)
- pharmacotherapy (mirtazapine, paroxetine, setraline, olanzapine)
- psychological interventions (trauma-focussed CBT, eye movement desensitisation and reprocessing (EMDR)
NB: no evidence of benefit of a single session debriefing
PTSD history taking: key features?
- Current mental state
- past psych history
- developmental history
- employment history
- substance use history
- risk to self and others
- what led to breakdown of a relationship
- why denied access to son
Management of PTSD following treatment?
- severe PTSD: engagement problems
- ongoing evaluation of risk to self and others
- treat comorbidity (substances misuse)
- physical health checks
- social support
- voluntary work/ employment
- carer’s assessment
Prognosis of PTSD?
- 56% improve after psychotherapy (not meeting diagnostic criteria)
- 38% contintue to have residual symptoms
- highest remission rates seen in natural disaster survivors (60%)
Risk factors for PTSD prognosis?
- trauma severity
- lack of social support
- additional post trauma life stressorts
PTSD and DSM grades?
DSM I (1952): traumatic neuroses (shell shock, battle neurosis, combat stress) DSM II (1968): transient situational disturbances DSM III (1980): PTSD (re-exp, hyperarous, avoid..) DSM IV (1994): PTSD- 3 clusters of symptoms and assoc features DSM V (2013): 4 cluster symptoms (negative alterations in cognitions and mood)
Features of traumatic neuroses?
- restlessness
- exaggerated startle response
- psychomotor retardation
- confusion
- nausea
- vomiting
- withdrawal
- paranoid reactions
Behaviour of PTSD w/ DSM grades?
DSM I (1952): fundamentally resilient and able to bounce back; underlying individual weakness DSM II (1968): underlying character weakness or constitutional vulnerability DSM III (1980): sig. symptoms of distress in most ppl DSM IV (1994): normal response to catastrophic trauma DSM V (2013): ?individual (resilience)
Problems w/ current DSM classifications of PTSD?
- complex PTSD (Herman, 1992)
- disorders of extreme stress, not otherwise specified, DESNOS (Van der Kolk et al, 1996)
- enduring personality change after catastrophic experience, EPCACE (ICD 10)
Define Enduring Personality Change After Catastrophic Experience (EPCACE)?
Change of at least four years in a
person’s pattern of perceiving, relating to, or thinking about the
environment and self following exposure to catastrophic stress
Main features of Enduring Personality Change After Catastrophic Experience (EPCACE)?
- permanently hostile/distrusting
- social withdrawal
- constantly feeling empty/hopeless (maybe w/ increased dependency on others), prolong depressive mood without evidence of depressive disorder
- “on edge”/feeling threatened
- permanent feeling of being changed/different to others
Define catastrophic trauma?
Prolonged exposure to life-threatening circumstances w/ imminent possibility of being killed (e.g. exposure to war trauma, concentration camp experience, torture, hostage situations and sexual assault)
NB: based on ICD-10 description of catastrophic stress
Define complex PTSD
exposure to an event/several of extremely threatening or
horrific nature, most commonly prolonged or
repetitive events from which escape is difficult
or impossible (torture, slavery, genocide
campaigns, prolonged domestic violence,
repeated childhood sexual or physical abuse)
Criteria of complex PTSD?
ICD-11 (2018):
- criteria for PTSD met
WITH severe and persistent:
- affect regulation problems
- feeling worthless/shame/guilt
- difficulties sustaining relatioships
Problems with ICD
- CPTSD overlaps with personality disorder criteria -> diagnostic confusion
- risk factors are same for CPTSD and personality disorder (sexual/physical abuse)
- ?preferance for CPTSD (stigma attached to personality disorder diagnosis)
- ?treatment of CPTSD vs personality disorder treatment
Literature on relationship w/ personality change and PTSD?
Munjiza et al, 2014:
- lasting personality pathology following catastrophic trauma
- EPCACE in 2.6% and 6% with no personality disorder history pre-trauma
- 20% increase in adult onsent anti-social behaviour after trauma
Limitations of literature of relationship w/ personality change and PTSD?
Munjiza et al, 2014:
LIMITATIONS
- no prospective studies
- few retrospective studies on EPCACE]- recall bias?
- no investigation of personality pre-trauma
- no controls
- methodological heterogeneity
More literature on trauma and personality pathology?
- case control: war trauma is a risk factor for interpersonal dysf 15 yrs after armed conflict
- restrospective: personality disorder can be developed from adult trauma; this may be as severe as ones of earlier onset
ICD-10 criteria vs reported symptoms?
Existing ICD-10
- permanent hostility/distrust
- social withdrawal
- fells empty and hopeless
- “on edge”/threatened
- feels changed/different to others
Additional personality athology observed (>50% pts)
- mood changes
- anger control problems
- impulsiveness
- feels cold/detached
- feels odd/eccentric
- oversensitive to criticism
- inflexible/rigid
- identity problems
- no desire for intimacy
- no life enjoyment
- increased suicide idealation/self harm threats
