Week 10: Stress and trauma Flashcards
PTSD used to be considered what in the DSM5?
Anxiety disorder
What characterizes PTSD?
Re-experiencing, avoidance, negative changes in thoughts and mood, and hyperarousal following exposure to a traumatic event
What is the first line of treatment for PTSD?
Trauma focussed therapy
What can you treat PTSD with if not trauma-focused therapy?
Non-trauma focussed therapies
Medications
ECT - triggers a brief seizure
What medication is used for PTSD?
SSRIs
What is focal brain stimulation?
It is a potential stand-alone treatment for PTSD
Involves applying energy to specific brain regions to alter the activity of a brain site as well as its connections
What are the 3 focal brain stimulation techniques and how invasive are they?
Deep brain stimulation (DBS) - most focal but the most intensive
Transcranial magnetic stimulation (TMS): less focussed than DBS but also not as invasive
Transcranial direct current stimulation (tDCS): this is non-focal and non-invasive
What is vagus nerve stimulation used for?
to indirectly stimulate neural targets via this nerve
What two brain structures are involved in PTSD but are hard to stimulate because of their location in the brain?
- Amygdala
- Hippocampus
How can you reach the amygdala to stimulate it?
You can target indirectly via prefrontal structures through TMS or through DBS (however for DBS it requires surgery and has risks)
What do we see in the brain when first-line treatments to PTSD don’t work?
Hyperactivation of the amygdala
Reduced hippocampal volume
DBS to stimulate the amygdala has found…
a clinical improvement in PTSD symptoms
Trauma can result from…..
One or multiple threatening and stressful events
What does trauma result in?
Persistent negative effect and activation of the threat system
What is the basic route of the threat system?
Sensory information coming into the system that is centred around the amygdala and output from the autonomic nervous system and the HPA axis
What are some persistent negative effects that may result from trauma?
Intense fear Terror Loss of hope Anxiety Guilt Shame Hyperarousal
What are the specific trauma and stress-related disorders in the DSM5
PTSD Acute stress disorder (ASD) Adjustment disorder Reactive adjustment disorder Disinhibited social engagement disorder Unclassified or unspecified trauma disorders
What might stress and trauma disorders be comorbid with?
Depression Substance abuse Eating disorders Self-harming behaviors Dissociative behaviors Personality disorders
For adults and children over the age of 6, what are the PTSD symptoms?
Upsetting memories Feeling on edge Having trouble sleeping World feels unsafe May try and avoid things that remind them of the trauma
Who can develop PTSD?
Anyone at any age
What increases the likelihood of PTSD?
Very intense or very long-lasting traumatic events
Also getting injured
What kind of traumatic events is PTSD more common following?
Combat
Sexual assault
What are the categorical symptoms of PTSD according to the DSM5? (see notes for in depth)
- Exposure to the actual or threatened, death, serious injury or sexual violence
- presence of one or more of the following intrusive symptoms associated with the event after it has occured
- avoidance of stimuli associated with the event
- marked alterations in arousal and reactivity with two of the following
For PTSD diagnoses, the symptoms have to last for ……… and cause……….. but not be due to……..
- One month
- Distress or impairment in social, occupational, or other important areas of functioning
- Physiological effects of a substance or another medical condition
What is the acute phase of ASD?
It is where the diagnosis of ASD can be made
3 days - 1 month
What if ASD symptoms last for longer than a month?
The clinician would assess for PTSD and ASD diagnosis would no longer apply
What is the debate around ASD and PTSD?
Debated whether or not ASD is a predictor of PTSD
How many PTSD symptoms does ASD have to meet?
At least 9 of the 14
What are the categorical symptoms of ASD according to the DSM5? (see notes for in-depth)
- Exposure to the actual or threatened death, serious illness, or sexual violence
- Negative mood
- Dissociative symptoms (altered sense of reality or inability to remember important aspects of the event)
- Avoidance symptoms
- Arousal symptoms (sleep disturbance, anger, hypervigilance, cant concentrate)
How do ASD and PTSD differ in how they meet criteria and are diagnosed?
PTSD required meeting a certain number of symptoms from established clusters, ASD are not clustered, just need to meet a certain amount overall
PTSD includes non-fear based symptoms, ASD does not
Trauma focussed psychotherapies with the most evidence are?
- Prolonged exposure
- Cognitive processing therapy
- Eye movement desensitization and reprocessing
What is prolonged exposure?
Teaches you how to gain control by facing your negative feelings.
It involves talking about your trauma and doing some of the things you have avoided since
What is cognitive processing therapy?
Teaches you to reframe your negative thoughts about the trauma
It involves talking with your provided about your negative thoughts and doing short writing assignments
What is eye-movement desensitisation and tracking
Helps you to make sense of your trauma, calling it to mind while paying attention to a back and forth movement or sound such as a finger waving or a light/tone
Fear is…
A subjective state
Physiological responses elicited by threatening stimuli through activation of the HPA axis and ANS, also behavioral responses
What is threat detection?
A protective bodily response vital for survival
What is the evolutionary perspective of threat detection?
The brain has prewired circuits that respond to ancestral threats
How do we learn to respond to new threats?
Neural plasticity in fear circuits
What is considered fear pathology?
Fear response is inappropriate to the stimulus or in magnitude
What is the james-lange theory of emotion?
Emotion inducing stimulus triggers specific physiological and behavioural responses in the person
The person then interprets these responses which is the emotion
What is the cannon-bard theory of emotion?
There is a stimulus that promotes physiological and behavioural responses as well as an emotional experience simultaneously.
What is the fear center model?
Threat into sensory system
Into the fear circuit
Leads to a fear response - defensive behaviour and physiological responses
What is the two-systems model of fear?
One system is for generating conscious feelings of fear (cognitive circuit)
One system is for controlling behavioural and physiological reactions (defensive survival circuit)
They both do have some interaction with each other
What does the hypothalamus do
Regulates many functions such as the HPA axis through the pituitary gland
What was Papez’ argument?
Emotional states are expressed through the effect of the limbic system on the hypothalamus
Emotion is experienced through the effect of the limbic system on the cortex
How does sensory information travel to the amygdala
It comes into the thalamus and travels to the amygdala in the temporal lobe it goes down to the body to trigger the physiological responses there are two ways of this information gets here
The low road and the highroad
What is the Low Road in relation to sensory information travelling to the amygdala
The low road is a direct route straight from the thalamus to the amygdala
What is the highroad in relation to sensory information travelling to the amygdala
The highroad is indirect it goes from the thalamus to the sensory cortex then to the amygdala
When the sympathetic nervous system is activated what kind of physiological symptoms do we see
Increased heart rate, inhibited saliva, dilated bronchial, inhibited digestion, dilated pupils
What drugs dampen down the sympathetic nervous system
Beta-blockers
The HPA axis enables what
Fight or flight
Explain the HPA axis
It involves the hypothalamus, pituitary gland and adrenal gland
The hypothalamus controls the secretion of hormones from the Pituitary gland by secreting CRH
The pituitary releases ACTH
These hormones released travel down to the kidneys the adrenal glands that secrete the hormone cortisol
Cortisol will eventually affect all cells in the body and feeds into the brain infection hippocampus and the pre-frontal cortex that are particularly sensitive
this corresponds with memory deficits under extreme stress cortisol also increases the amygdala response
What does the adrenal cortex release?
Glucocorticoids (including cortisol)
What does the adrenal medulla release?
Catecholamines
