Session Nineteen (PTSD)

Question 1

Outline the DSM-5 criteria for the diagnosis of PTSD?

Answer 1

A: Must count as traumatic
B,C,D,E: Must meet all 4 symptom criteria
F: Must last for 1 month or more
G: Must cause significant distress or interference
…and can’t be explained by the effects of a substance or medication

Question 2

What qualifies as ‘trauma’ under the DSM-5 PTSD criteria?

Answer 2

Quite strictly defined, event that involves actual or threatened death, injury or sexual violence. Can be:

• Experiencing or witnessing a single event
• Learning about an event
• Repeated exposure to a traumatic stimulus

Question 3

What are the 4 key symptoms of PTSD which must be met for a diagnosis to be reached (criteria B-E)?

Answer 3

B = Re-experiencing symptoms.

C = Avoidance symptoms

D = Negative alterations in cognition and mood

E = Alterations in arousal and reactivity

Question 4

What are the re-experiencing symptoms of PTSD, and how many are required for a diagnosis? (Criteria B)

Answer 4

At least one of:

• Distressing memories
• Nightmares
• Dissociative reactions
• Distress when exposed to reminders

Question 5

What are the avoidance symptoms of PTSD, and how many are required for a diagnosis? (Criteria C)

Answer 5

Only one; avoiding reminders of trauma (required for diagnosis)

Question 6

What are the negative alterations in cognition and mood symptoms of PTSD, and how many are required for a diagnosis? (Criteria D)

Answer 6

At least two of:

• Forgetting aspects of event
• Negative beliefs
• Loss of interest
• Detachment

Question 7

What are the alterations in arousal and reactivity symptoms of PTSD, and how many are required for a diagnosis? (Criteria E)

Answer 7

At least two of:

• Irritability
• Anger
• Destructive behaviour
• Hyper-vigilance
• Difficulty in concentrating
• Poor sleep

Question 8

How common is trauma generally, and how do most people respond to it?

Answer 8

Incredibly common:

• Kilpatrick et al, 2013: 90% of US adults experience some form of traumatic event in their lifetime
• Most experience more than one in fact (3 being the mean)
• Common causes = violent death of a friend or family member, witnessing severe injury or death, being involved in an RTA

Normal response for most people is to develop some mild PTSD symptoms that recover over about a month.

Question 9

How prevalent is PTSD generally?

Answer 9

Prevalence of PTSD after trauma =

• 11% for women
• 5% for men
• 8.3% overall

Question 10

What factors affect likelihood of traumatic reaction developing into PTSD?

Answer 10

Stressor factors:

• Type of trauma (interpersonal violence, combat)
• Prolonged or repeated trauma
• Grotesque events, events involving children tend to be more strongly associated with PTSD

Personal characteristics:

• Women more at risk than men
• Black or hispanic at greater risk than white
• Personal or family history of psych disorders (D or A)
• Previous trauma
• Low intelligence

Subjective response:

• How the person perceives their life to be threatened, loss of control etc
• Mental defeat
• Dissociation
• Anger, guilt or shame

Question 11

Aside from PTSD, what conditions are associated with the experience of trauma?

Answer 11

• Major depression
• Anxiety disorders
• Substance abuse

Question 12

What 3 forms of trauma are classically associated with PTSD, and what % of individuals go on to develop the condition?

Answer 12

Rape:

• 65% men
• 46% women

Combat:
- 39%

Physical abuse:

• 22% men
• 49% women

Question 13

What did Brewin et al’s 2000 meta-analysis into risk factors for PTSD show?

Answer 13

Factors with a strong effect on development of PTSD:

• Trauma severity
• Lack of social support
• Additional life stress

Reasonable effect:

• Psych history
• Reported childhood abuse
• Fam history

Variable effect:

• Education
• Prior trauma
• General childhood adversity

Possible:

• Female sex
• Race
• Age at trauma

Question 14

What conditions are commonly seen in PTSD patients?

Answer 14

• Very strong co-morbidity with depression (88%M, 79%F)
• Strong co-morbidity with alcohol abuse (52%M, 30%F) (this could be a self-medication thing)
• Ohayon et al (2000) found 60% of PTSD sufferers also experience insomnia symptoms, vs 6-15% of general population

PTSD also appears to have an effect on general health, with increased risk of:

• CVD
• Diabetes
• Alzheimer’s
• Early death

Question 15

What factors can predict developing chronic PTSD?

Answer 15

Recovery environment:

• Social support
• Absence of negative responses from others
• Further stressful or traumatic events including aftermath of trauma

Psych maintenance factors:

• Dysfunctional appraisals
• Trauma memory characteristics
• Dysfunctional behaviours or cognitive strategies

Sleep problems, both before and after the event

Question 16

Why is PTSD so commonly poorly treated?

Answer 16

• Often unrecognised, especially in children
• On average takes 10 years before patients receive adequate treatment
• Secondary problems have developed by that point, making it harder to treat

Question 17

Outline the evidence supporting the role of Cortisol in PTSD?

Answer 17

Evidence for:

• Olff et al (2005): PTSD patients show low basal cortisol levels, probably due to increased receptor number leading to more sensitive cortisol negative feedback inhibition of the HPA axis
• Wessa et al (2006): Expanded on this by associating cortisol directly with PTSD symptom severity

Evidence against:

• Meewisse et al (2007): Meta-analysis + SR of evidence, found no significant different in cortisol levels
• Methodological limitations rampant in evidence for
• Cortisol alone unlikely to explain core PTSD symptomatology

Problem of cause vs effect

Question 18

Outline the neuroanatomical/ fMRI evidence surrounding the cause of PTSD?

Answer 18

Liberian et al, 2006:

• Impaired functioning in sub regions of mPFC and anterior cingulate regions
• Increased responsivity of the extended amygdala and insula regions
• Amygdala role in exaggerated emotional responses in PTSD

Bremner et al, 2003:
- Women with PTSD who were exposed to childhood sexual abuse show smaller hippocampal region as well as less HC activation

Again issue of cause vs effect

Question 19

Which region of the brain is most strongly associated with dysfunction in PTSD?

Answer 19

The Amygdala (+ Hippocampus)

Hull et al, 2002:

• Most replicated structural difference = hippocampal volume reduction
• This may limit the proper evaluation and categorisation of experience
• Patients display increased activity in the amygdala after symptom provocation

Woon et al, 2008:
- Differences in the hippocampus and amygdala in adults who experienced child maltreatment vs those who didn’t

Teicher explains these differences in terms of preparing the brain for a threatening and uncertain environment.

Question 20

Outline the evidence regarding the role of genetics in PTSD?

Answer 20

Pitman et al, 2006:

• US twin study
• Twins who’d been exposed to combat showed a greater heart rate response
• However both exposed and non-exposed twins showed increased neurological soft signs as well as decreased hippocampal volume
• Suggesting that both had a vulnerability, which when exposed to a trigger lead to symptoms of PTSD

Stein et al, 2002:
- 30% of variance in PTSD symptoms could be attributed to genetics

Question 21

How might the cortisol and brain theories of PTSD interact?

Answer 21

• People with smaller hippocampi have a higher PTSD risk
• Potentially because smaller hippocampus can increase strength of fear conditioning and reduce regulation of HPA axis
• Causing hypersensitivity in brain areas that assess salience and respond to threat

Furthermore, it could also be that altered levels of cortisol directly influence the brain itself by damaging the hippocampus

Question 22

What evidence from therapy points away from an explanation of PTSD based entirely on psychopharmacology?

Answer 22

• CBT + Sertraline works better than Sertraline alone
• CBT works better than Sertraline independently at preventing relapse
• Medication is not used as first line treatment under NICE guidelines

Suggests there is more to PTSD than pure psychopharmacology

Question 23

Outline the behavioural model of PTSD?

Answer 23

PTSD as a learned response:

• First, trauma occurs leading to a normal fear response
• Stimuli surrounding the fear response (e.g. water in near-drowning, loud noises in combat, men in rape victims..) become paired with the unconditioned stimulus (drowning, rape…)
• Become a conditioned stimulus which illicit the same response as the trauma stimulus
• This conditioned stimulus then generalises, so many more stimuli cause the same effect in the patient

Question 24

Give some evidence in favour of the behavioural/conditioning model of PTSD?

Answer 24

• Provides a compelling account of re-experiencing of symptoms in PTSD patients
• Shalev et al, 1993: People with PTSD show greater physiological reactivity to trauma related cues following trauma exposure
• Keane et al, 1998: PTSD severity moderates responsively to these cues
• Holmes et al, 2004: Changes in psychophysiology can predict development and persistence of PTSD as well as treatment outcome

Question 25

What could be the mechanism for fear conditioning in PTSD?

Answer 25

- Increased acquisition of fear learning OR - Reduced extinction of fear learning - Lommen et al, 2013: reduced extinction learning in soldiers deployed to Afghanistan predicted PTSD severity for greater than factors such as personality measures, stress levels and even exposure to stress while on deployment

Question 26

Outline the Cognitive Model of PTSD?

Answer 26

PTSD occurs due to differences in how information is stored and processed: - Suggests that individuals prone to emotional disorders preferentially attend to emotionally congruent cues, recall more unpleasant memories and interpret ambiguous events in a more negative way - This model emphasises the importance of appraisals of the event, symptoms and reactions to them, changing beliefs about the self, the world and others

Question 27

What are the 3 components to cognitive models of PTSD?

Answer 27

Information processing: - Attention, memory, learning and problem solving disrupted - Attentional biases may exist in anxiety disorders Schemas: - Ways the brain stores information - Influences ongoing thinking and processing - Encourages black and white thinking - Over general memory Faulty meaning: - e.g. panic attacks seen as signalling impending death

Question 28

Outline the "Shattered Assumptions" model of PTSD?

Answer 28

Janoff-Bulman et al, 1992: - People have existing world schema; assumptions of personal invulnerability and world as meaningful, self viewed in a positive light - Trauma occurs - Unable to integrate their trauma into their existing schema (e.g. the world is safe) - Then one of two processes occurs - ASSIMILATION, where the new information in integrated into the old assumptions - ACCOMMODATION, where changes in assumptions are made to accommodate with the new experience - Both producing new schema

Question 29

Give some criticisms of the Shattered Assumptions model of

Answer 29

- Why is prior exposure to trauma (e.g. in childhood) a risk factor for PTSD? If this theory is correct it should be protective as no alterations to existing schema should be required - How are memories and beliefs represented in this model? - If schemas are universal why do only certain people develop PTSD - Why are intrusive memories triggered so automatically? Model doesn't explain this

Question 30

Outline the Dual Representation theory of PTSD?

Answer 30

- Multi-level theory, suggesting there are multiple ways in which information is represented in the brain - Two memory systems operate in parallel during and after trauma - Situationally accesible vs Verbally accessibly memories (alternatively named S-Reps and C-Reps) - Suggests that non-conscious, rapid processing is stored in a different code to conscious processing - S-reps are distinct from our normal episodic memories

Question 31

What are S-Reps and C-Reps in the dual representation model of PTSD?

Answer 31

S-Reps = VISUOSPATIAL aspect of memory: - Accessed automatically when person re-enters context - Sensory, physiological and motor aspects of a trauma are coded in this way and can be recreated (as flashbacks) - POORLY INTEGRATED WITH C-REPS DUE TO TRAUMA C-Reps = CONTEXTUAL aspect of memory: - Conscious experience of trauma, easily retrieved from store of autobiographical experiences - Easily communicated verbally - Intentionally retrieved - Greater hippocampal encoding (Brewin, 2001) If the two are well integrated, fear is inhibited when S-rep becomes activated. In the trauma memories of PTSD patients, the two are poorly bound together which creates some of the symptoms of PTSD.

Question 32

What did Brewin et al, 2004, show about PTSD in support of the dual representation model?

Answer 32

- Asked 62 adults with PTSD for detailed written trauma narratives - Flashback sections were compared to ordinary sections - Showed greater detail, mentions of death, use of the past tense, mention of fear, helplessness and terror - Patients displayed more autonomic and motor behaviours while describing them - Evidence for the distinctiveness of S-reps

Question 33

What did Holmes et al, 2004, show about PTSD in support of the dual representation model?

Answer 33

- Asked patients to watch a 12.5 minute video of real-life post RTA footage - Divided into three conditions; no secondary task, secondary task that interfered with S-reps, secondary task that interfered with C-reps - Visuospatial interference (which prevented S-rep encoding) lead to reduction in flashbacks - Verbal interference (which prevented C-rep encoding) lead to increase in flashbacks - Supports not only their distinction but the role their lack of unity plays in PTSD symptomatology

Question 34

Outline Ehlers and Clark's 2000 model of PTSD?

Answer 34

- PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat - This current threat results from NEGATIVE APPRAISALS of the trauma and or its sequelae + a disturbance of autobiographical MEMORY (poor contextualisation, strong associative memory and strong perceptual priming) - Sensation of current threat manifests as intrusions, arousal symptoms, strong emotions

Question 35

What is abnormal about PTSD memories?

Answer 35

Paradoxical: It is difficult to intentionally remember trauma but patients are plagued by involuntarily triggered intrusive thoughts, e.g. - Sensory impressions (rather than thoughts) - Here and now quality - Affect without recollection Ehlers highlights this nature to PTSD memories as one of the 2 essential properties that create the "sensation of current threat" in PTSD (the other being negative appraisals)

Question 36

What research has been done into the nature of PTSD memories?

Answer 36

Ehlers et al, 2017: - Trauma memories more vivid - More recurrent and persistent than non-trauma memories - Led to greater suppression

Question 37

What negative appraisals might a trauma patient make and what is the significance of these?

Answer 37

According to the Ehlers model, negative appraisals (along with the unusual nature of PTSD memories) are what generates the persistent sense of threat seen in these patients. Examples: - Nowhere is safe - A disaster will happen soon - I attract disaster - I deserve bad things to happen to me - My personality has changed for the worse - I'm dead inside - I'm going mad (flashbacks) - My brain is damaged - I can't trust people / people pity me - My body is ruined Essentially they can develop negative appraisals over a number of factors, ranging from the fact the trauma happened, how they responded to it, how others treat them, the symptoms of PTSD...

Question 38

According to the Ehlers model. what is the effect of the negative appraisals seen in PTSD?

Answer 38

Negative appraisals directly generate negative affect and anxiety + Lead to dysfunctional coping: - Thought suppression - Rumination - Avoidance - Addiction and self medication

Question 39

Give some evidence for the Ehlers and Clark model of PTSD, 2000?

Answer 39

- Good empirical support, Ehlers et al (2010) provides support for the here and now, vivid, lack of context nature of the memories - Large prospective longitudinal studies such as Kleim et al (2007) support - Cognitive processes account for 40% of variance in PTSD symptoms - Model appears to be specific to PTSD, works less for depression or phobias

Question 40

What "early intervention" approaches have been attempted for PTSD?

Answer 40

Debriefing: - Single session treatment - Allows patient to review the trauma and express themselves emotionally - Can review perceptions of what happened - Normalise symptoms - Encourage them to talk about their experiences Pharm prevention of PTSD with: - Propanolol - Hypnotic medication Various specific courses of treatment for selected people at high risk of chronic symptoms

Question 41

How effective is the debriefing approach to PTSD prevention?

Answer 41

Mayou et al, 2000: - Single debriefing session within 1 month of traums - At 4 month, ineffective - At 3 years, debriefing led to worse psychiatric symptoms, travel anxiety, worse functioning, greater financial problems Conclusion: At best ineffective, at worst has adverse outcomes

Question 42

What evidence is there to support the role of CBT in PTSD?

Answer 42

Ehlers et al, 2003: - RCT comparing CBT, self help and repeated assessments as forms of early intervention for trauma patients identified as high risk of PTSD chronicity - Those whose symptoms hadn't recovered after 1 month were put into one of the 3 - Results: Cognitive therapy most effective (89% recovered) - Sustained after 9 months

Question 43

According to NICE guidelines, when should practitioners intervene for PTSD cases?

Answer 43

Patient presents: - DO NOT use debriefing session - Watchful waiting for people with mild symptoms, follow up at 1 month (this is because PTSD within one month of trauma is normal) - If symptoms still present at 1 month, consider passing them on for CBT intervention - Short, individual CBT for people with severe PTSD symptoms in first month

Question 44

When should medication be considered in PTSD

Answer 44

If.... - Adult patient, does not want or respond to psych therapy - Patient under serious current threat - Consider as adjunct therapy if very severe co-morbid depression or hyper-arousal Avoid prescribing to children

Question 45

What medications are commonly used for PTSD?

Answer 45

General use: - Paroxetine - Mirtazapine Mental health specialists: - Amitriptyline - Phenelzine

Question 46

Outline the NICE guidelines for PTSD?

Answer 46

- 1 month cooling off period - All patients with PTSD should be offered a course of trauma-focused CBT or Eye movement desensitisation and reprocessing - 8-12 sessions depending on severity, comorbidity or repeated trauma - Children get CBT

Question 47

What are the benefits of exposure therapy for PTSD?

Answer 47

- Can use imaginal exposure such as narrative writing or in vivo exposure - Reduced affect - Clarify what happened - Develop a coherent narrative Known to be effective - Prolongued exposure therapy supported by research evidence from Fox (1991 and 1999) - Supported by 2010 meta-analysis from Powers

Question 48

What are the vital components to Cognitive therapy according to the Ehlers model?

Answer 48

- Elaborate on nature of memory - Identify and modify negative appraisals - Reduce current threat risk - Give up strategies intended to control threat or symptoms

Question 49

Give some evidence for CBT for PTSD?

Answer 49

Bisson et al, 2005: - Very effective - Can be done in conjunction with exposure, cognitive structuring

Question 50

Give some evidence in favour of cognitive therapy?

Answer 50

Ehlers et al, 2003: - Shown to be very effective - Superior to other active treatments such as supportive counselling - Large effect sizes

Question 51

What are the components of TF-CBT?

Answer 51

Trauma Focused- CBT: - Cognitive assessment - Reliving imagery work - Identify hot spots in trauma memory - Update hot spots - Identifying thinking errors - Addressing guilt cognitions, anger, shame, avoidance - Stimulus discrimination - Site visits

Question 52

What is the link between PTSD and sleep?

Answer 52

Unclear but there does appear to be one: - Trauma can cause insomnia independently of PTSD - Insomnia is a risk factor for the development of PTSD - Many patients benefit from having their insomnia managed before their PTSD (might even work in the initial one month stage) - 50% of recovered PTSD patients retain some sleep issues - Sleep therapy could be used to enhance PTSD treatment efficacy - Sleep problems slow response to PTSD treatment