PTSD

Question 1

Psych sx following exposure to trauma

Answer 1

Anxiety
fear

anger
aggression
dysphoria
dissociation

Question 2

time course for subtypes of PTSD

Acute stress disorder
Acute PTSD
Chronic PTSD
Delayed Onset PTSD

Answer 2

Acute stress disorder
- 0-1 mo

Acute PTSD
-0-3 mo

Chronic PTSD
- long

Delayed Onset PTSD
- 6+ mo

Question 3

PTSD DSM A

Answer 3

6+ years old

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: does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

Question 4

PTSD DSM B

Answer 4

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).

Question 5

PTSD DSM C

Answer 5

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).

Question 6

PTSD DSM D

Answer 6

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).

Question 7

PTSD DSM E

Answer 7

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).

Question 8

PTSD DSM other
time etc

Answer 8

Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.

• 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.

Question 9

PTSD DSM specification

dissociative sx
depersonalization
derealization
delayed expression

Answer 9

Specify whether:

• With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:
• Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
• Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).
• With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Question 10

TRAUMA

Answer 10

traumatic event
re experience
avoidance
unable to function
month (at least)
Arousal

Question 11

70% exposure to trauma and % develop PTSD

Answer 11

6%

Question 12

Negative sx of PTSD look like

Answer 12

depression

Question 13

Note for DSM you need sx of ___ and ___

Answer 13

intrusive sx

avoidance

Question 14

fear conditioning and response

Amygdala
Thalamus
Hippocampus

Answer 14

Amygdala
- remember stimuli associated with fearful event
- send response to hypothalmus (endocrine)
-send response to PFC (emotions)
- send response to brain stem/Locus (motor/ANS)

Thalamus
- sensory input to amygdala

Hippocampus
-remembers the context of the fear conditioning

Question 15

fear extinction

Answer 15

Progressive reduction of the response to a fear stimulus

new learning allows inhibition of fear response

GABA suppress glutamate driver fear response

Question 16

Fear dysregulation

Answer 16

deficit in fear extinction

inc generalization of fear

neg bias of threat from neutral stimuli

feeling danger in a safe environment

Question 17

Tx prioritization

Answer 17

CBT
EMDR
psychotherapy
- multiple types

Question 18

Rx tx FDA approved for PTSD and initial dose

Answer 18

Paroxetine 10-20mg qd

Sertraline 25-60mg qd

Question 19

Rx tx for PTSD with strongest recc

Answer 19

Paroxetine
Sertraline

Also:
fluoxetine
venlafaxine

note mult moderate reccs including risperidone (only antipsychotic though not all guidelines recommend)

Question 20

Key NT for amygdala

Answer 20

serotonin

Question 21

civilian vs combat response

Answer 21

civilian>combat

Question 22

Prazosin for PTSD

Answer 22

a1 adrenergic receptor antagonist

CNS activity during sleep provides the rationale (nighttime sx)A

crosses BBB

Question 23

Antipsychotics evidence for PTSD

Answer 23

may dec glutamate and promote neurogenesis

may reduce re-experiencing and hyperarousal sx

Tx psychosis, poss in PTSD

concern for cardiometabolic AE

Question 24

Antipsychotics RX for PTSD

Answer 24

Multiple guidelines against but some say ok for adjunct and esp r/t disabling sx and behaviors or psychosis

Risperidone
-mixed response

olanzapine
- small trial

quetiapine
- small trial

Question 25

BZD evidence for PTSD

Answer 25

inc GABA effect small rct show no improvement vs placebo some trials suggest worse - may interfere with extinction potential misuse

Question 26

MDMA evidence for PTSD

Answer 26

2017 study as breakthrough tx seems to inc tolerability and effectiveness of psychotherapy Pooled RCT showed significant improvement in PTSD sx and reduced overall depression longitudinal study show sx improved after 12 mo

Question 27

Cannabinoids evidence for PTSD

Answer 27

pos studies - improved sleep, dec anxiety/nightmares/hyperarousal/flashback some studies show no change or worse PTSD sx/violence/alcohol