Week 2 - A - Response to trauma, Trauma 1 and 2, Freeze v flee, PTSD diagnosis criteria and treatment

Question 1

Traumatic events can be classified as type 1 and type 2 trauma What is the difference between type 1and2 trauma?

Answer 1

Type 1 trauma - this is where there is a single incident of truama and is unexpected

Type 2 trauma - also known as complex trauma is repetitive and includes ongoing abuse and hostage taking

Question 2

Is type 1 or type 2 trauma more likely to result in PTSD?

Answer 2

Type 2 trauma is 3 times more likely to result in PTSD than type 1 trauma

Question 3

Is trauma more likely to affect higher or lower socioeconomic classes?

Answer 3

Trauma is much more likely yo affect lower socioeconomic clases

Question 4

What percentage of patients with bipolar disorder have a history of childhood deprivation or abuse?

Answer 4

According to a study, childhood deprivation or abuse is linked to 50% of cases of bipolar disorder

Question 5

The two responses to threat are freeze or flee What do these mean? • Fight, flight, freeze, hide, avoid, attach, submit, despair & uncontrolled activation states all originate from what area of the brain? This area is the area of the brain that is also very much involved in analgesia modulation

Answer 5

Freeze is what happens when there is a distant or inescapable threat

Flee is when the threat is nearby and escapable

The area where all the freeze/flee and others airse in response to a threat is the periaqueductal grey (PAG) area - this is the area in the mdibrain around where the cerebral aqueduct lies

Question 6

“Freeze” responses To distant threat can be voluntary – i.e., “stop, watch and listen” pattern of vigilance When ‘inescapable’ threat – “Tonic immobility” occurs When does tonic immobility occur and what is it?

Answer 6

Tonic immobility occurs especially in direct physical contact with a predator/aggressor

It is an involuntary state of profound (but reversible) motor inhibition

Question 7

What are some features of tonic immobility?

Answer 7

There is decreased vocalisation

There is rigidity and paralysis

Muscle tremors in extremities

Chills

And unresponsiveness to pain

Question 8

Why is it thought that tonic immobility may enhance survival?

Answer 8

It is less likely that predators are going to attack immobile prey and if they do they, immobility may cause them to loosen grip increasing chances of escape

There is also a decreased risk of violence in those who do not fight back and some predators may lose interest if victim immobile and unresponsive

Question 9

How does increased proximity to a predator shift the brain activity?

Answer 9

Increased proximity to a predator shifts the brain activity from the prefrontal cortex to the midbrain superior colliculi and periaqueductal

Question 10

• PTSD – suggested that it is associated with a deficiency in top-down modulation of amygdala activation by the prefrontal cortex It is thought that are three looping mechanisms in response to trauma What are these three looping mechanisms?

Answer 10

First loop - midbrain / brainstem origin - PAG and superior colliculi

Second loop - mesolimbin dopamine system

Third loop - Stimulus response learning system ie the structures that hold learning

Question 11

Name the 3 looping defence systems again? What happens to the cortisol levels in PTSD?

Answer 11

The 3 looping defence sytems are

The midbrain / brainstem loop - PAG and superior colliculus

The mesolimbic doapmine response

The stimulus response learning system

In PTSD the cortsiol levels are low - this is a biological paradox in response to acute stress

Question 12

What is the criteria for PTSD? How many of each type of symptom? What is the duration of the symptoms that allows for distinguishing between PTSD and Acute stress reaction?

Answer 12

There has to have been a traumatic event in which there are intrusive symptoms - 1+

avoidance sympotms - 3+

increased arousal - 2+

and the duration of these symptoms is at least one month after the event

Question 13

What is the intrusive phenomena? (need at least 1)

Answer 13

Recurrent distressing recollections

Nightmares

Flashbacks

Pshyiological reactions fight or flight

Distress accompanies reminders

Question 14

What are the avoidance symptoms that can happen in PTSD? (need at least 3)

Answer 14

Avodiance of thinking or talking about the event

Avoidance of reminders such as activities, places or people

Amnesia for important aspects such as trauma

Loss of interest in activities

Detachment

Question 15

What are the hyperarosual symptoms that may be present in a patient with PTSD? (Need at least 2)

Answer 15

Sleep disturabcne

Irritability/anger

Concentration difficulties

Hypervigilance

Exaggerated startle response

Question 16

A number of sufferers with PTSD may recover with no or limited interventions. However, without effective treatment, many people may develop chronic problems over many years. The severity of the initial traumatic response is a reasonable indicator of the need for early intervention, and treatment should not be withheld in such circumstances. IF someone presents where symptoms are mild and have been present for less than 4 weeks after the trauma

Answer 16

Watchful waiting if the symptoms have been present for less than 4 weeks and then follow up one month later

Question 17

If someone presents with severe symptoms for less than 3 months, what is the management? If someone presents with symptoms for greater than 3 months, what is the management?

Answer 17

If someone preents with severe symptoms for less than 3 months or symptoms for greater than three months

1st line is - trauma focussed psycotherpay - CBT or eye movement desensitization and reprocessing (EMDR)

Question 18

For PTSD sufferers who have no or only limited improvement with a specific trauma-focused psychological treatment, healthcare professionals should consider the following : * an alternative form of trauma-focused psychological treatment * the augmentation of trauma-focused psychological treatment with a course of pharmacological treatment. What drugs are shown to possibly have effect in PTSD patients? (limited evidence exists)

Answer 18

For non specialists Mirtazapine (Atypical NaSSA) or paroxetine (SSRI)

Specialists - amitriptyline (TCA) or phenelzine (MAOI) PTSD is not a normal adaptation to severe (traumatic) stress.

• * • PTSD is not an inevitable response to trauma
• * • PTSD is not the only response to trauma
• * • most trauma-exposed people do not develop PTSD
• * • many individuals will recover quickly from PTSD or only ever have brief distress