Criteria of PTSD
-Exposure to actual or threatened death, serious injury, or sexual violence
-Intrusion symptoms associated with the traumatic event (distressing memories, dreams, flashbacks, distress with reminder of trauma)
-Persistent avoidance of reminders of the trauma
-Negative changes in cognition/mood
-Marked changes in arousal or reactivity
-Duration of >1 month
Changes in cognition and mood with PTSD
Need at least two of the following:
-Inability to remember important aspects of the trauma
-Exaggerated negative beliefs (about self, others, or world)
-Self-blame for the trauma
-Persistent negative emotions
-Diminished interest in activities
-Feeling detached from others
-Inability to experience positive emotions
*Note that there is a lot of overlap with MDD
Changes in arousal and reactivity in PTSD
Need at least two of the following:
-Irritable behaviour + angry outbursts
-Reckless/self-destructive behaviour
-Hypervigilance
-Exaggerated startle response
-Problems concentrating
-Sleep disturbances
Acute stress disorder
Similar to PTSD but <1 month
Adjustment disorder
Maladaptive reaction to a stressor, improves within 6 months after the stressor is resolved
Moral injury
The damage done to someone’s conscience when they perpetrate, witness, or fail to prevent acts that go against their own morals and values
Complex PTSD
*Not a DSM-5 diagnosis
All PTSD criteria are met plus additional severe + persistent symptoms (problems with affect regulation, low beliefs about self, difficulty sustaining relationships)
When complex PTSD may develop
-After extremely threatening or horrific traumas
-When trauma is prolonged and/or repetitive
-When escape is difficult or impossible
Ex: torture, genocide, prolonged domestic violence, repeated childhood abuse
Pre-traumatic event risk factors for PTSD
-Female sex
-Low IQ
-Prior trauma
-Prior mental disorder
-Personality factors
-Genetics
Psychiatric comorbidities with PTSD
-Bipolar disorder
-Depression
-Substance use disorder
-Physical injury/chronic pain
-Cluster B personality disorders
-Psychosis
Post-traumatic event risk factors for PTSD
-Increased HR
-Low social support
-Financial stress
-Pain severity
-ICU stay
-Traumatic brain injury
-Peritraumatic dissociation
-Acute stress disorder
-Disability
Fear conditioning
A form of classical conditioning where an innate (unconditioned) physiological response to fear gets paired with a previously neutral (conditioned) stimulus
Exposure therapies
Address fear conditioning - exposure to the conditioned stimulus in a safe environment can lead to extinction
Medications that can improve exposure therapy
Ones that increase neuroplasticity - boost the brain’s capacity to learn and change, making exposure therapy more powerful
-D-cycloserine
-SSRIs
Dysregulated circuits in PTSD
People with PTSD show abnormalities in regulating the sympathetic NS and the HPA-axis, making their stress-response systems hyperactive
Mechanism for dysregulated circuits in PTSD
Normally, the amyglada and the prefrontal cortex inhibit each other in balance. When the prefrontal cortex is active (calm, reflective state), it inhibits the amyglada to keep emotions and stress under control
In PTSD, amyglada activation is exaggerated (more emotional) and prefrontal cortes function is diminished (less rational). Pathways downstream of the amyglada mediate hyperarousal, increased HR, and enhanced startle
Management for dysregulated circuits
-SSRIs help reduce amyglada activation
-Early exposure to manageable stress = more resilience
-Neurostimulation therpies - promising but not yet
Memory reconsolidation and it’s implication in PTSD
Essentially, long-term memories are not fixed - every time a memory is recalled, it is temporarily “flexible” again and must be reconsolidated - opportunity for memory to be changed/updated
In PTSD, repeated recall of traumatic memories can reinforce maladaptive beliefs and interpretations about the trauma
Management for memory reconsolidation in PTSD
Exposure therapy - allows memories to be updated with new perspectives/emotions because the reconsolidation occurs in a safe and reassuring environment
What med helps enhance benefit of exposure therapy?
Propanolol (beta blocker) - given before exposure
Which biological treatment might prevent PTSD
within 24 hours of injury?
Morphine
*Propanolol has not been shown to reduce PTSD but does enhance the benefits of exposure therapy
Interventions in the first 4 days after tauma to reduce chance of PTSD development
-Attend to safety + basic needs
-Provide access to resources (physical, emotional, social)
-Psychological first aid for management of acute stress
-Don’t do psychological debriefing - may actually increase the likelihood of developing PTSD
Psychotherapies for PTSD
-Cognitive processing therapy: helps people identify and challenge negative thoughts and beliefs about their trauma
-Exposure therapy
-CBT
-Eye movement desensitization and reprogramming
First line pharmacotherapy for PTSD
SSRIs
*Avoid benzos - they just numb further and keep avoidance going (counterproductive)
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