PTSD

Question 1

How is PTSD defined by DSM 5?

Answer 1

• Exposure to actual or threatened death, serious injury or sexual violence (1 or more)
  
  • Directly experiencing the traumatic event
  • Witnessing in person, the event(s) as it occurred to others
  • Learning that it occurred to close family member or close friend (even must be violent or accidental)
  • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)

Question 2

What are the 3 symptoms clusters of PTSD?

Answer 2

• Intrusions
• Avoidance
• Hyperarousal

Question 3

What are intrusions?

Answer 3

• Traumatic event is persistently re-experienced
  
  • Recurrent & intrusive distressing recollections
  • Recurrent distressing dreams
  • Dissociative rxns: acting or feeling as if reliving the event (Continuum: to complete loss of awareness of the present)
  • Intense psychological distress at exposure to internal or external cues
  • Physiological reactivity to exposure to cues

Question 4

What is avoidance?

Answer 4

• Persistent avoidance of stimuli associated w/ the trauma
  
  • Efforts to avoid distressing memories, thoughts, feelings, about the traumatic event
  • Avoid external reminders activities, places or people, conversations, objects, situations that arouse recollections

Question 5

What is the “numbing” process that is a component of avoidance?

Answer 5

• Negative alterations in cognitions & mood (“numbing”)
  
  • Inability to recall important aspects of the trauma
  • Persistent & exaggerated negative beliefs or expectations about self, others or world
  • Persistent, distorted cognitions about the cause or consequence of the event
  • Persistent negative emotional state (fear, guilt, shame, anger)
  • Markedly diminished interest or participation in activities
  • Feeling of detachment or estrangement from others
  • Persistent inability to experience positive emotions

Question 6

What is hyperarousal?

Answer 6

• Persistent symptoms of increased arousal, marked alterations in arousal & reactivity
  
  • Sleep disturbance, difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
  • Reckless or self-destructive behaviors

Question 7

What is the Horowitz Theory of Integration?

Answer 7

• Over-control
  
  • Numbing
  • Denial
  • Dissociation
  • *negative alterations in mood & cognitions
• Under-control
  
  • Flashbacks
  • Nightmares
  • Hyperarousal
  • *intrusions

Question 8

PTSD

Duration of symptoms > ______
Disturbance causes significant _____ or _________ in social, occupational or other important areas of functioning

Answer 8

>1 month

distress, impairment

Question 9

What is the prevalence of traumatic events in PTSD?

Answer 9

• 80% of population exposed to traumatic event
• Disasters may create significant impairment in 40-50% of those exposed
• Up to 45% of those exposed to natural disaster may develop PTSD or major depression or other psychiatric symptomatology

Question 10

What are the crisis-related symptoms of PTSD?

Answer 10

• Anxiety, Panic
• Elevated startle response
• Insomnia
• Anger
• Helplessness
• Depression
• Suicidal ideation
• Impulsivity
• Violence
• Self-Medication

Question 11

What are the 3 key neurobiological players of trauma?

Answer 11

• Amygdala
  
  • PET imaging shows amygdala activation to traumatic vs. neutral stimuli
• Hippocampus
  
  • Reduced hippocampal volumes
• Prefrontal cortex
  
  • LESS activation

Question 12

What are some highlights of the amygdala regarding PTSD?

Answer 12

• Set of nuclei at the center of each temporal lobe
• Dozen distinct areas, 2 involved in fear conditioning
• Receive inputs from senses & memory; physiologic & behavior outputs
• “Quick & dirty route” vs. cortical route makes processing implicit
• No conscious effort required
• **Amygdala activation mediates anxiety **

Question 13

How are defense responses elicited from the amygdala?

Answer 13

Innate or learned sound –> Auditory Thalamus –> Auditory Cortex –> Lateral Amygdala –> Central Amygdala

• From the Central Amygdala:
  
  • Central Gray: Freezing
  • Lateral Hypothalamus: BP
  • Paraventricular Hypothalamus: Hormones

Question 14

What are some highlights of the hippocampus regarding PTSD?

Answer 14

• The hippocampus contextualized fear & regulates it on the basis of the situation we are in
• Context is a psychological construction; a memory created on the spot about the various factors involved in a situation

Question 15

_________ hippocampal volume may be related to memory dysfunction in PTSD.

Answer 15

Reduced hippocampal volume may be related to memory dysfunction in PTSD

Question 16

What are some highlights of the prefrontal cortex regarding PTSD?

Answer 16

• PFC & Amygdala are reciprocally related
• When PFC is activated, the amygdala is inhibited, making it harder to express fear
• The behavior of animals w/ PFC damage is similar to humans w/ PTSD: they develop fear rxns that are highly unregulated

Question 17

Prefrontal Cortex-Amygdala Pathways

Answer 17

Question 18

Dysfunction in 3 main brain areas related to PTSD

Hyperactivity of the ______ has been shown in neutral conditions
________ _______ & _________ activation are inversely related
_______ decreased volume

Answer 18

amygdala

prefrontal cortex, amygdala

hippocampus

Question 19

What are some fundamentals of psychotherapy for PTSD?

Answer 19

• Traumatic memories are stored in a state of high physiologic arousal
• Traumatic events are state dependent
• **Therefore, traumatic memories must be accessed in a state of similar emotional arousal **

Question 20

PTSD

Behavior Treatment

Behavior Deconditioning

Answer 20

• Behavior Treatment
  
  • Anxiety attempts to avoid fear-evoking stimuli
  • PTSD (avoidance) blocks exposure that promotes extinction
  • Focus on exposure treatments to facilitate extinction
• Behavioral Deconditioning
  
  • Rate of Exposure
  • Flooding (implosive therapy)
  • Systematic desensitization

Question 21

What are the 3 types of therapy pathways?

Answer 21

Different pathways for 3 different types of therapy

• Talk therapy (PFC-L; not directly connected to A)
• CBT (PFC-M; directly connected to A)
• Drug (directly connected to A & other brain areas)

Question 22

What are different types of cognitive behavioral therapies?

Answer 22

• Stress Innoculation Training
• Imagery Rescripting & Reprocessing Therapy
• Cognitive Restructing Within Reliving
• Imaginal/In-vivo Exposure
• Prolonged Imaginal Exposure
• Cognitive Processing Therapy

Question 23

Physician Screening Tool: Type I Trauma

Questions

Changes

Answer 23

Single incident

• Questions
  
  • Have you experienced any vivid thoughts about the accident/injury?
  • What do you believe is the cause of the accident/injury?
  • Are you able to return to the place of the accident/injury?
  • What do you think could be done to prevent the accident/injury?
• Changes
  
  • Problems w/ concentration
  • Sleep disturbances
  • Hypervigilance/increased startle response
  • Increased irritability
  • Changes in mood
  • Changes in appetite

Question 24

**Physician Screening Tool: Type II Trauma **

Problems

Answer 24

Multiple/prolonged

• Somatic complaints; all diagnostic resting is negative
• Chronic depression and/or anxiety
• Difficultly sleeping
• Difficulty concentrating
• Memory problems: chunks of time during childhood that are not remembered
• Flashback, nightmares or images of the past that continually intrude
• Startle response grater than witnessed in others
• Difficult w/ appetite/food or textures that are unappealing
• Difficulty identifying, experiencing, tolerating or expressing anger
• Problems knowing who to trust

Question 25

What are some **comorbidities** of PTSD?

Answer 25

* Panic Disorder * Agoraphobia * OCD * Social Phobia * Specific Phobia * Major Depressive Disorder * Somatization Disorder * Substance-Related Disorders