Trauma Related Disorders Flashcards
PTSD, Acute Stress Disorder
What is trauma? (according to DMS5)
Death, threatened death, actual or threatened serious injury or actual or threatened sexual violence, which includes direct exposure (by learning from a close friend or relative) and repeated or extreme indirect occupational exposure.
Traumatic experiences can be divided into two categories, namely interpersonal (such as IPV) and non-interpersonal traumas (such as natural disasters)
What is acute stress disorder?
- acute stress reaction within the first four weeks after exposure to a traumatic event
- symptoms typically begin immediately after the traumatic event and persist for at least three days and up to one month
- the symptomatology includes dissociative, re-experiencing, avoidance, negative moods and hyperarousal symptomatology
What are the 7 key features of PTSD as per the DSM 5
1 - exposure to trauma
2 - re-experiencing the event
3 - avoidance and numbing
4 - negative alterations in cognition and mood
5 - hyper-vigilance and arousal
6 - duration of one month or more
7 - significant distress and functional impairment
Why should benzos be avoided in acute stress disorder?
They suppress the cognitive and emotional processing
What are the four symptoms clusters in PTSD
Intrusion
Avoidance
Mood
Alterations in arousal and reactivity
Comment on the pathophysiology of PTSD (9)
- genetic risk factors account for 30-40% of the heritability of PTSD
- early childhood adversity is a risk factor
- the HPA axis and sympathetic nervous system seem to be hyper-responsive in PTSD
- the acute stress response is characterized by elevated corticoid release and elevated peripheral cortisol levels
- those with PTSD have low ambient cortisol levels
- functional brain imaging shows excessive amygdala activity and reduced activation of the prefrontal cortex and hippocampus
- structural brain imaging shows reduced volumes of the hippocampus and the anterior cingulate
- the flashbacks may be explained by these processes
- additionally elevated cortisol levels may be neurotoxic, resulting in possible hippocampal atrophy
What are four screening tools used in the assessment of PTSD?
- PC - PTSD - Primary Care PTSD Screen
- LEC - 5 - life event checklist for DSM-5
- TEQ - Traumatic Events Questionnaire
- CAPS-5 - Clinician Administered PTSD Scale for DSM-5
What are some psychotherapy options for the treatment of PTSD?
- Trauma-focused CBT - prolonged exposure therapy (PE)
- CPT - cognitive processing therapy. Combination of cognitive therapy and written accouns of the trauma
- Eye Movement Desensitization and Reprocessing - used dual stimuli/eye movements to facilitate emotional processing and stress management
- Desensitization
- Cognitive restructuring
NB Early psychological debriefing has not been proven to prevent PTSD. It may have a negative impact on recovery.
What are some adjunctive pharmacotherapy options for the treatment of PTSD?
SSRIs
SNRIs
Alpha-adrenergic receptor blockers - for nightmares and insomnia
Atypical antipsychotics
Benzodiazepines and hypnotics
List the DSM-5 criteria for PTSD
(A) Exposure ot actual or threatened death, serious injury, sexual violence
- direct experience
- witnessing trauma
- learning that it occured to a close family or friend
- Repeated to extreme exposure to aversive details of traumatic events
(B) INTRUSION
- recurrent, involuntary and intrusive distressing memories
- recurrent distressing dreams
- dissociative reactions such as flashobacks
- intense or prolonged psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event
- marked physiological reactions to stimuli that resemble the event
(C) AVOIDANCE
- avoidance of or efforts to avoid distressing memories, thoughts or feelings about or closely associated with the traumatic event
- avoidance of or efforts to avoid external reminders that arouse distressing memories
(D) COGNITION OR MOOD
- inability to remember certain aspects of the event
- negative beliefs about ones self
- distorted cognitions about the cause or consequences of traumatic events
- negative emotional state
- diminished interest or participation in significant activities
- detachment or estrangement from others
- inability to experience positive emotions
(E) AROUSAL AND REACTIVITY
- irritable behavior and angry outbursts
- reckless or self-destructive behaviour
- hypervigilance
- exaggerated startle response
- problems with concentration
- sleep disturbance
(F) more than a month
(G) clinically significant distress or impairment in social/occupational or other important areas of functioning
(H) not attributable to effects of a substance or another medical conditions
What are the PTSD specifiers?
- With dissociative symptoms
Depersonalization
Derealization - With delayed expression - full criteria not met until at least 6 months after the event
How do the diagnostic criteria for PTSD differ in kids less than 6 years
A - exposure to event
B - Intrusion (emphasis on manifestation through play)
C - Combines the Avoidance and effect on Cognitions and Mood
D - alterations in arousal and reactivity
EFG the same and the same specifiers
What are the diagnostic criteria for Acute Stress Disorder?
(A) - exposure to trauma
(B) Presence of nine or more of the following symptoms from any of the FIVE categories of
1 - INTRUSION
- recurrent intrusive memories
- dreams
- dissociative reactions (flashbacks)
- psychological or physiological distress
2 - NEGATIVE MOOD
- inability to experience positive emotions
3 - DISSOCIATIVE SYMPTOMS
- altered sense of reality of one’s surroundings or oneself
- inability to remember an important aspect of the traumatic events
4 - AVOIDANCE SYMPTOMS
- avoid distressing memories, thoughts of feelings
- avoid external reminders
5 - AROUSAL SYMPTOMS
- sleep disturbance
- irritable behavior and angry outbursts
- hypervigilance
- problems with concentration
- exaggerated startle response
(C) 3 days to 1 month after the trauma
(D) clinically significant distress
(E) not attributable to effects of substance, another medical condition or brief psychotic disorder.
What are the “before trauma” risk factors for PTSD?
- family history of trauma and PTSD
- underlying psychiatric history such as underlying PD
- mood and psychotic disorder
- female
- childhood trauma
What are the “during trauma” risk factors for PTSD?
- nature of the trauma
- duration of the exposure to trauma
- how the patient interprets the traumatic incident at the time of the incident
- intoxication
