Trauma/Stress disorders Flashcards
Trauma and Stress Disorders
patho
The most primal function of the brain is to keep us alive. Trauma affects the brain
Limbic brain: “reptilian brain”, develops in utero, located in the brain stem, tells us to cry, void, eat; shape in response to experience- emotions, safety, pleasure, threat
Traumatized people perceive the world differently
After trauma, the brain and nervous system have altered sense of risk and safety
Cortisol levels remain elevated in a person who has been exposed to stress or trigger
MRI of people with trauma look different ( activated right hemisphere (intuitive, emotional, visual, spatial, and tactual brain- carries feelings related to an experience) and deactivated left hemisphere ( linguistic, sequential, and analytical- does the talking)
Leads to people being “stuck” in fight or flight. You cannot process an event if you are overwhelmed by it- stuck in R brain thus cannot be logical (L brain); remains “raw and undigested”
Trauma and Stress Disorders
general
Define trauma
Sx after a trauma include
Trauma: overwhelming amount of stress that exceeds person’s ability to cope/process the emotions involved in that experience
Traumatic events can be singular or repeated
Symptoms after a trauma include:
Anhedonia, dysphoria, externalized anger/aggression, dissociative symptoms
Sequela of trauma/stress include
Depression, anxiety, substance abuse
trauma disorders
Pharm and non-pharm Tx
Psychotherapy
Weekly for 90 minutes over 8-12 weeks
Lifestyle Changes
Physical activity, regular sleep schedule, yoga, regular daily routine, avoiding alcohol, drugs, sugar drinks; support groups
Rx
SSRI
Atypical antipsychotics
Self-monitor symptoms
Keep journal
mood diary
educated to monitor symptoms due to risk of relapse
Types of Traumatic Stress Disorders
Acute Stress Disorder (symptoms: 3 days post event, < 4 weeks)
Post-traumatic stress disorder ( symptoms > 4 weeks)
Reactive attachment disorder
Disinhibited social engagement disorder
Grief Reaction
Adjustment Disorders ( symptoms within 3 months, resolve within 6 months)
Acute Stress Disorder
Time frame
Symptoms within 1 month of a traumatic event
Lasts 3 days to 1 month
Considered a precursor to PTSD
*PTSD can develop at any time after event and lasts > 1 month
Post-Traumatic Stress Disorder
general and time frame
Proximity to stressor determines the severity
Less distance from stressor –less exposure required to trigger
Ie: near a threat, hear of a threat, vs experience threat
Exposure can be: experienced, witnessed, learned, or repeated aftermath
Debrief (sooner vs later)- very controversial
Life threatening vs life-altering
often patient is unaware that they have
If not identified patient prone to develop mood disorder and substance abuse
Can develop any time after event and lasts > 1 month
Women most often related to rape or assault
Men most often related to combat
First responders/police most often related to traumatic event
Often overlap with PTSD, depression, panic disorder
Reaction formation defense mechanism
Diagnostic Criteria for PTSD
Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly experiencing the traumatic event(s).
Witnessing, in person, the event(s) as it occurred to others.
Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).Note:Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).Note:In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).Note:In children, there may be frightening dreams without recognizable content.
Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)Note:In children, trauma-specific reenactment may occur in play.
Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs).
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest or participation in significant activities.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
Reckless or self-destructive behavior.
Hypervigilance.
Exaggerated startle response.
Problems with concentration.
Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
Post-Traumatic Stress Disorder
Presentation
Presentation
Intrusion: unwanted thoughts/dreams, behaviors secondary to trigger
Mood change: usually depression, irritability
Dissociation: feeling of numbness, estrangement, detachment
Avoidance: avoiding place, people, or activities
Arousal: hypervigilance ( not anxiety), irritability, insomnia, poor concentration, exaggerated startle, sleep disturbance
must have one of these for duration > 1 month
Reactive Attachment Disorder (F94.1)
general
Age of Dx and tx
Develops in infancy/ childhood
Fail to form bonds and attachment, emotionally withdrawn from caregiver
“care to little”
Does not seek out comfort when distressed, does not respond to comfort when offered
Must rule out autism and learning disability
Diagnosed by 5 yoa
Tx:
Needs to include the care giver
Hard to treat
Play therapy and Expressive therapy: multisensory processes that include games and art
Make children feel safe
Fun activities with care givers
Rx not indicated
Prone to develop mood disorder, anxiety, substance abuse
Disinhibited Social Engagement Disorder (F94.2)
general and tx
Develops in infancy/ childhood ( < 5 years)
Due to social neglect
Fail to form bonds and attachment
“care too much”
Overly bond to everyone/anyone
Do not adhere to “normal” boundaries
Usually, a response to severe neglect thus look for:
Signs of physical maltreatment, poor nutrition, rashes
Excessive hunger/thirst
Flattened back of head
Failure to thrive/growth retardation
Tx:
Play therapy and Expressive therapy: multisensory processes that include games and art
Rx not indicated
Adjustment Disorder (F43.2)
general and tx
Non-life-threatening stressor which causes depression/anxiety that is disproportionate than event
Onset < 3 months from event, < 6 months duration
Symptoms include rebellious behavior, anxiety, depression
No suicidal or homicidal ideation
Tx:
CBT and Psychodynamic Psychotherapy- the emphasis is to become aware of thoughts and decisions and their influence on their lives
Grief Reaction (F43.81)
general and tx
Reaction to a loss
Normal grief resolves 6 months-1 year
Abnormal grief: sever symptoms > 1 year or suicidal ideation, psychosis, illusions/hallucinations that patient perceives are real
*prolonged grief disorder
Tx: psychotherapy
Rx based on symptoms
For several months, a 32-year-old housewife has been unable to leave her house unaccompanied. When she tries to go out alone, she is overwhelmed by anxiety and fears that something terrible will happen to her and nobody will be there to help
Agoraphobia
Panic disorder
Obsessive-compulsive disorder
Social phobia
Specific phobia
*A- agoraphobia; treatment of choice is exposure therapy
A 50-year-old policeman is terrified of needles.
Agoraphobia
Panic disorder
Obsessive-compulsive disorder
Social phobia
Specific phobia
How do you Tx?
E- specific phobia, treatment of choice- exposure therapy
Two years after she was saved from her burning house, a 32-year-old woman continues to be distressed by recurrent dreams and intrusive thoughts about the event.
A. Generalized Anxiety
B. Panic disorder
C. Adjustment disorder
D. PTSD
E. Specific phobia
F. Acute stress disorder
How do you Tx?
D- PTSD; treatment EMDR/CBT
A 20-year-old student is very distressed by a small deviation of his nasal septum. He is convinced that this minor imperfection is disfiguring, although others barely notice it.
Agoraphobia
Body Dysmorphic Disorder
Obsessive-compulsive disorder
Social phobia
Specific phobia
Body Dysmorphic Disorder
A 35-year-old woman is often late to work because she must shower and dress in a very particular order or else she becomes increasingly anxious.
A. Agoraphobia
B. Panic disorder
C. Obsessive-compulsive disorder
D. Social phobia
E. Specific phobia
How do you Tx?
C- OCD. Treatment SSRI, CBT
A middle-aged bank teller with a history of alcohol abuse, who describes himself as a chronic worrier, has been promoted to a position with increased responsibilities. Since the promotion, he has been constantly worrying about his job. He fears his superiors have made a mistake and they will soon realize he is not the right person for that position. He ruminates about unlikely future catastrophes, such as not being able to pay his bills and having to declare bankruptcy if he is fired. He has trouble falling asleep at night and suffers from acid indigestion.
Generalized Anxiety
Panic disorder
Obsessive-compulsive disorder
PTSD
Specific phobia
Generalized Anxiety
Which of the following is drug of choice for OCD?
Clomipramine (Anafril)- TCA
Clonazepam (Klonopin) -sedative
Methylphenidate (Daytran) -stimulant
Sertraline (Zoloft)- SSRI
SSRI of choice would be sertraline; however if resistant may use clomipramine ( watch side effects)
Which is therapy of choice for anxiety disorder?
Which is the therapy of choice for PTSD?
Which is the therapy of choice for phobias?
Which is the therapy of choice for panic attacks?
A-Anticonvulsants
B-Antipsychotics
C-Cognitive behavioral therapy
D-ECT and pharmacotherapy
E- exposure therapy, flooding and graduated
F- EMDR
G-TMS
Anxiety: Cognitive behavior therapy; drug of choice would be SSRI
PTSD: EMDR
Phobias: exposure therapy
Panic attacks: flooding and graduated exposure
Patient presents with recurrent panic attacks. You diagnose them with generalized anxiety and panic attacks. What is drug of choice for chronic management?
A- Alprazolam (Xanax)
B- Buspirone (Buspar)
C- Gabapentin (Neurontin)
D-Mirtazapine (Remeron)
E-Sertraline (Zoloft)
E- Chronic drug of choice would be sertraline ( ssri); in addition to CBT and poss prn anxietlyic
Which of the following therapies is best for treatment of panic attacks?
A- Acupuncture
B- EMDR
C- Flooding and Graduated Exposure
D- Meditation
E- Transcranial Magnet Stimulation
C- Flooding and Graduated Exposure
Which of the following therapies is best for treatment of post traumatic stress disorder?
A- EMDR
B- Medication
C-Transcranial Magnet Stimulation
D- Flooding and graduated exposure
EMDR is approved for PTSD. Concept is quick debriefing/therapy and not as many sessions post event
Remember that PTSD has symptoms longer than 1 month- Acute stress disorder is > 3 days but < 1 month
What is the therapy of choice for specific phobia?
A- Exposure therapy
B- CBT
D-Psychoanalysis
E- EMDR
Exposure therapy for phobias
CBT to treat anxiety
EMDR for PTSD
SSRI Pearls
Fluoxetine and escitalopram can be used in adolescents- fluoxetine preferred for depression ( more studied)
Black box warning SSRI pediatrics
Wellbutrin can help with addiction disorders ( tobacco) and ADHD; no sexual side effects
Mirtazapine good for weight gain
Sertraline good for postpartum, more sedating of ssri
Escitalopram and citalopram have less drug interactions
Venlafaxine more N, can raise BP, wean off slowly
Discontinuation Syndrome
Sx
Educate patients that they should not simply stop SSRI
FINISH:
F: flu-like symptoms
I: insomnia
N: nausea
I: imbalance
S: sensory disturbances
H: hyperarousal
Benzodiazepine Pearls
Alprazolam Shortest half-life
Clonazepam and lorazepam have longer half-life thus less addictive
Be cautious of patient asking for benzodiazepines
Check EMDR
Weaning schedules may be done inpatient
Delima of inheriting high dose long term patients
Increased falls in elderly
PTSD
