Trauma + Dissociative

Question 1

PTSD criteria (adults)

Answer 1

A) Exposure
B) At least ONE intrusive symptom
C) At least ONE avoidance symptom
D) At least TWO negative alterations in cognition and mood
E) At least TWO alterations in arousal and reactivity
F) More than 1 month

Question 2

PTSD specifiers

Answer 2

With dissociative symptoms

With delayed expression (criteria met only 6 month after trauma)

Question 3

PTSD criteria (kids)

Answer 3

< 6 yo

At least ONE intrusive symptom
At least ONE avoidance or negative cognition/mood
At least TWO alteration arousal and reactivity

No reckless/self-destructive behaviour
Traumatic exposure criteria does not include repeated or extreme exposure

Question 4

What percentage of those experiencing a trauma develop PTSD?

Answer 4

15-25%

Question 5

What percentage of PTSD have co-morbidities?

Answer 5

80%

66% have at least TWO

Question 6

PTSD neurobiology

Answer 6

Hippocampal atrophy
Smaller anterior cingulate cortex (proportional to severity)
Increased right-sided changes

Increased amygdala activity

Deactivation of Broca’s in flashbacks

Increased catecholamines
Activated opioid system

Low cortisol = ENHANCED SUPPRESSION OF CORTISOL ON DEXAMETHASONE CHALLENGE

Hyperregulated HPA

Question 7

PTSD risk factors

Answer 7

Childhood trauma
Personality disorder
Poor support
Female
Family hx psych disorder
Recent stressful life changes
External locus of control
Recent ++ EtOH

Question 8

Acute stress disorder

Answer 8

3 DAYS TO 1 MONTH

AT LEAST NINE (9) SYMPTOMS

• all intrusive
• can’t experience positive emotions
• can’t remember details of trauma
• dissociative symptoms
• all avoidance
• all arousal except reckless/self-destructive

50% of PTSD patients had ASD

Question 9

Conversion rate from ASD to PTSD?

Answer 9

25-30%

Question 10

EMDR also used for what anxiety disorder?

Answer 10

PHOBIAS

Question 11

SSRIs may not be as effective for which PTSD population?

Answer 11

Combat veterans

Question 12

Adjustment disorder

Answer 12

Development of emotional or behavioural symptoms in response to an identifiable stressor occurring WITHIN 3 MONTHS of the onset of the stressor (which can be of any severity)

At least ONE
- marked distress out of proportion
AND/OR
- impaired function

NOT exacerbation of pre-existing mental condition

Once stressor/consequences have terminated, symptoms don’t persist for more than an additional 6 MONTHS

Most return to normal within 3 months
Adolescents on average take longer

Question 13

Most common diagnosis in a hospital psychiatric consultation setting?

Answer 13

Adjustment disorder (50%)

Question 14

Adjustment disorder specifiers

Answer 14

with depressed mood
with anxiety
with mixed anxiety and depressed mood
with disturbance of conduct
with mixed disturbance of emotions and conduct
unspecified

Question 15

Other specified trauma-related disorder

Answer 15

Persistent complex bereavement disorder

Question 16

PTSD treatment

Answer 16

Rx > Psychotherapy

1st line
Paxil, Effexor XR > Prozac, Sertraline

Adjunctive
2nd line - Zyprexa, Risperdal, Zopiclone

Not recommended
Celexa
Clonazepam/Xanax
Desipramine
Epival
Zyprexa (mono)
Tiagabine

Propranolol not helpful in treatment or prevention

Question 17

Therapy vs. Rx in anxiety disorders

Answer 17

PTSD
Rx > psychotherapy
TF-CBT = EMDR (faster with EMDR + can do multiple traumas at once)

OCD
Combo > Rx
Combo = CBT
Individual = group

Panic d/o
Combo > Rx or CBT alone (acute)
Combo = CBT alone (maintenance)
Less relapse with CBT when Rx stopped
6 sessions as good as 12 sessions

Social anxiety d/o
CBT = Rx
CBT gains last longer

GAD
CBT = Rx = relaxation technique
Individual = group (but faster with individual)

Specific phobia
Rx NOT recommended
Gradual = flooding

Question 18

PTSD - nightmare treatment

Answer 18

Prazosin

Nabilone

Question 19

PTSD - flashback treatment

Answer 19

NALTREXONE

Question 20

3 stages of trauma therapy

Answer 20

1. Stabilisation
2. Trauma integration (live in the present)
3. Reconnection

Question 21

Reactive attachment disorder criteria

Answer 21

BOTH:

• rarely seeks comfort when distressed
• rarely responds to comfort

At least 2:

• minimal responsiveness to others
• limited positive affect
• unexplained irritability/sadness/fearfulness

Experienced pattern of extremes of insufficient care (at least 1):

• social neglect
• repeated change of primary caregiver
• rearing in unusual setting severely limit opportunities

RULE OUT AUTISM

Symptoms present between 9 months and 5 years old

Specify:

• persistent
• severe (if have all symptoms)

Question 22

Reactive attachment disorder types

Answer 22

Inhibited (RAD): tends to normalize over time in good environment

Disinhibited (social engagement disorder): behavioural patterns persist even when newly attached

Recovery:
PHYSICAL > emotional

Question 23

Disinhibited social engagement disorder

Answer 23

At least 9 months old

Not limited to impulsivity
Can be diagnosed concurrently with ADHD

Question 24

DID gold standard scale?

Answer 24

SCID - dissociative disorder revised

Both diagnosis and severity

Question 25

Average # of identities in DID?

Answer 25

15 for women

8 for men

Question 26

Depersonalization/derealization disorder

Answer 26

Reality testing remains intact during episode

LOW co-morbidity with PTSD

Avoidant, borderline, OCPD