PTSD

Question 1

PTSD classification

Answer 1

> 1 month of:
- actual or threatened stressor (directly experiencing, witnessing, vicarious through family or job)
- 1+ INTRUSION (intrusive memories, dreams, flashbacks, distress to cues, physiological reactivity)
- 1+ AVOIDANCE of thoughts, memories, feelings, or external reminders
- 2+ negative alternations in COGNITIONS or MOOD (memory gaps, negative belief, distorted cognitions, diminished interest and mood, feelings detached)
- 2+ AROUSAL alteration (irritability, reckless, hypervigilant, startle, sleep, concentration)

Specify if Dissociative Symptoms:
- Depersonalization - detached from oneself
- Derealization - experience of unreality, distance or distortion

Question 2

Acute stress disorder

Answer 2

Acute stress symptoms (same as PTSD) 3+ days <1 month
- >1 month = PTSD

Question 3

Differentials

Answer 3

DID

Similarities DID and PTSD: Both stem from traumatic event, both have dissociative symptoms inc intrusions

Differentiate DID and PTSD:
PTSD symptoms of dissociation = associated with trauma
DID can have dissociation with no relation to trauma eg amnesia for everyday events (not only traumatic event) and intrusions unrelated to traumatic events (by dissociative identity states).
Interpersonal /early trauma = dissociation,
non-interpersonal trauma (EQ) = mood and anxiety symptoms PTSD

schizophrenia

• Worst manifestation is schizophrenia, then dissociation, then PTSD,

Question 4

Assessment

Answer 4

Trauma-informed - not pressure clients to disclose entire trauma initially (brief initially - not detail, come back to later)
Symptoms / Impact
Social support
Coping strategies eg substance use/avoid

Memory:
- Characterise nature of trauma memory and spontaneous intrusions – Gaps in memory, emotional hotspots, memory here and now quality

Question 5

Psychometrics

Answer 5

Trauma Severity Index 2
Impact of Events Scale-R

Question 6

Risk factors (pre, during, post)

Answer 6

• Biological vulnerability (Limbic system arousal)
• Psychological vulnerability
• Social support
• Peritraumatic dissociation = increased perceptual, decreased conceptual
• Pre trauma factors:
• personality (do they go to people for support, do they go to others to find their solutions),
• prior trauma (CHILD abuse, neglect),
• developmental History (do they talk about what they went through, have they had loss of a parent, parent not there for them, parent who had to look after other family members)
• Potential traumatic event: context of trauma, how severe it was, if we hear about physical abuse history we ask around it (who, how long did it last, what provoked it, how did they try to stop it, how often, was it associated with drinking etc)
• Initial response: freeze, fight, flight, can feel disconnected from our bodies,
• Post trauma factors: persons capacity to get support, way we interpret the event – someone who sees it as a joke vs as a predator. Psychologically we are interested in the response and process

Trauma is a response not an event
Trauma is not what happens to you, but what happens inside you

Question 7

Elher’s and Clark Cognitive Model

Answer 7

• PTSD occurs only if individuals process the traumatic event in a way which produces a sense of a serious current threat.
• 2 processes lead to a current sense of threat. This includes the appraisal of the event and the memory of the event.
• (1) Characteristics of the trauma, (prior experiences, beliefs, coping state of individual) influence
• (2) cognitive processing during the trauma event.
• 1+2 both influence the appraisal of the event and the memory of the event (data-driven).
• leading to sense of Current threat (eg intrusion, arousal, and emotion)
• leading to Strategies intended to control threat/symptoms (eg avoidance, substance use)
• but they maintain and prevent change in nature of the trauma memory and appraisals.

Question 8

Brewins Dual Representation Model of PTSD

Answer 8

Trauma memory if represented in 2 systems
- Situationally Accessible Memory (SAM) system: Perceptual (eg sensory, motor, physiological aspects) - responsible for flashbacks)
- Verbally Accessible Memory (VAM) system: Episodic (eg narrative memories of trauma), with good processing memories can be integrated and deliberately recalled

Cognitive processing during trauma
- LESS conceptual processing VAM (i.e. processing the meaning of the situation, processing it in an organized way and placing it into context) and MORE data-driven processing SAM (i.e. processing the sensory impressions) = trauma memory being difficult to retrieve intentionally.
- The memory trace will be poorly discriminated from other memory traces, thus impairing stimulus discrimination between stimuli present during the trauma and harmless stimuli that bear some similarity to these (colours, noises, etc)
- PTSD results when individuals cannot tolerate re-experiencing the event and therefore the event is never encoded into the long term, episodic memory, maintaining the flashbacks.

Question 9

Consequences

Not all trauma is equal

Answer 9

• Interpersonal = abuse, neglect, assault is more severe (leads to shame)
• non-interpersonal = natural disasters (lead to anxiety and fear)

Question 10

Treatment

Psychological debriefing?

Answer 10

PTSD
Trauma Focused CBT (&/or meds (SSRI’s) &/or EMDR (eye movement desensitisation treatment)

NICE guidelines:
1. Trauma focused CBT
2. Offer EMDR
3. CBT: specific symptoms (sleep, anger) ONLY if unable/willing to respond to trauma-focused tx or has residual symptoms
4. Consider SSRI / antipsychotic

TF-CBT
Acronym PRACTICE
ALL GRADUAL!!!

Psychoeducation
- Trauma responses, symptoms, rationale for tx, expectations for tx

Relaxation
- Reducing baseline arousal, coping tools, practice with trauma reminder

Affect identification and modulation
- Feelings chart, connect emotions to trauma reminders

Cognitive coping
- Thoughts feelings connection
- Accurate/inaccurate thoughts
- Only phase with no talk of trauma and reminders

Trauma narrative and processing
- Processing of trauma narrative (writing story and pull out cognitive distortions use socratic questioning and updating the trauma memory with more balanced thinking, imaginal exposure (skip over hot stops to start but repeat and explore deeper until memory no longer provokes anxiety), or using role play to rescript the trauma experience)
- Share account
- Minimise/extinguish intense negative response
- Contextualise their experience
- Use analogies (filing cabinite) to rational for this part
- Can be creative (comic book, song, news aricle, time line)

In vivo mastery

Con joint sessions

Enhancing safety

CBT
- Safety Behaviours - reviewing unhelpful beliefs and BE new possibilities.
- Misinterpretations can be reappraised by cognitive restructuring, using ‘standard’ CBT interventions.
- Selective memory processes teaching the technique of decentring, or standing back and viewing the cognitions at a distance. Gain a wider, more balanced perspective, which is less distressing.
- ‘Reclaiming your life’: re-engage survivors with meaningful activities; the aim of this is to improve the quality of their lives and their mood as well as helping them re-establish a more normal life style.

No psychological debriefing: a set of procedures including counselling and the giving of information aimed at preventing psychological morbidity and aiding recovery after a traumatic event.

Question 11

Cognitive model of PTSD

Answer 11

Trigger
= vivid, traumatic memories giving a sense of present threat/overestimation of danger
= high levels of anxiety
= safety-seeking behaviour
= failure to contextualise the memory (reminds vivid), failure to learn to accurately appraise danger

Question 12

Adjustmnt disorder (under mood and anxiety in DSM)

Answer 12

• Anxious or depressive reactions to stress (milder than PTSD symptoms) but still impairing
• *onset of symptoms within 3 months of the event, BUT > 6 months after the event = depression.

Question 13

Treatment

Answer 13

Treatment
- SUDS
- Physical interventions – exercise, healthy diet, reduction stimulant intake, rest, daily relaxation, breathing
- Behavioural intervention – activity scheduling to feel in control – self-soothing activities
- Cognitive intervention – not thoughts about trauma-related cognition but the general role of thoughts/feelings/behaviours connection
- PAIR WITH COGNITIVE Grounding exercises – bring to here and now not absorbed in painful memories – coping self-esteem “just relax” “remember to breathe” to “I expect to feel anxious but that’s ok I can handle it, I won’t make it worst by frightening thoughts” – put on cards carry around
- Systematic desensitization graded exposure – stay in a feared situation long enough for the anxiety to reduce – often increases before decreasing – will be worse than before if they leave when anxious and do not wait for it to reduce
o Come up with a list of activities they want to achieve – especially things they have been avoiding – should be specific and vary in difficulty for each goal ask them to estimate using SUDS how anxious they will be – list in order and start with the easiest – hard ones can break up (go to the park can be drive to park, stand on the corner, walk few steps etc)
o HW at least once a day (avoiding one day builds up fear) – general rule 3x in a row with suds of 40 or less than move on
o Monitor “date” “target” “time” “max suds” “end suds” “comments”
o Techniques to get calm  rehearse in mind  slow relaxed manner  keep eye on SUDS 80+ need to stop calm then go again  stay till calm (SUDS reduce by half)  reinforce for completing

• Imaginal exposure
  o Therapeutic relationship
  o Rationale (tooth decay dentist takes it out then puts filling not on top)
  o Can use MI if hesitant
  o Develop a hierarchy of trauma memories
  o Start with easiest
  o Get them to describe it from beginning to end, (want to peak at 70)
  o Repeat through the same scene
  o Warn that over days it can make intrusions worst
  o Can do HW by taping session and listening to it at home
  o Start with eyes open then eyes closed
  o Past tense than present tense
  o If too distressed “watch a movie or faraway”
• Write it out to make sense piece it together