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What is PTSD?

- Experience of a severe traumatic event of an exceptionally threatening nature which is likely to cause distress in anyone


What are the three main cluster of syndromes?

- Re-experiencing

- Hyperarousal

- Avoidance


What are features of reliving?

- Flashbacks

- Recurring memories related to the traumatic event

- Recurring dreams of the event


What are features of hyperarousal?

- Difficulty falling asleep

- Irritability and outbursts of anger

- Difficulty concentrating

- Exaggerated startle response (noise, fireworks)


What are features of avoidance?

- Efforts to avoid thoughts, feeling associated with the trauma

- Efforts to avoid activities, place and people that arouse recollections of the trauma

- Feeling detached from others

- Reduced interest in participation in important


What is the 4th factor of PTSD according the DSM-2013 four-factor model?

- Negative alterations in cognition and mood
- Persistent negative cognitions about, self,
others and the world
- Persistent negative emotional states (anger,
shame, fear)
- Diminished interest in significant activities
- Inability to experience positive emotions.


What are different types of trauma?

- Combat trauma
- Torture
- Terrorism
- Rape
- Witnessing violent death of others (war)


What are more types of trauma?

- Type I trauma - a single traumatic event (Terr,

- Type II trauma - prolonged and repeated

- Interpersonal vs natural disaster

- Intergenerational trauma

- Concept of catastrophic trauma (ICD 10,


What is the aetiology of PTSD?

- Not clear why some people develop PTSD and
some not

- Heritability 30% (Goldberg et al., 1990)

- Impaired sensitivity of HPA axis (Yehuda et al.,

- Reduced hippocampal volume


What is the prevalence of PTSD?

- Lifetime prevalence in general population 8%
(Kessler et al., 1995)

- Lifetime prevalence of PTSD in general
practice 14% (Gomez-Beneyto et al., 2006)

- 31% of Vietnam war veterans (The
National Vietnam Veterans Readjustment
study) had lifetime PTSD (Kulka et al. 1990)

- PTSD more prevalent in victims of
interpersonal trauma than disaster victims


What are features of a PTSD history?

- Current Mental state (triad of symptoms)

- Past psychiatric Hx (first contacts with mental health services, admissions; ?under section)

- Developmental Hx

- Employment Hx

- RIsk of self harm and harm to others


What are some comorbidities of PTSD?

- Alcohol abuse/dependence – M-52%; F-27%
(Kessler et al. 1995)

- Drug misuse – 34%

- MDD -48%

- Physical health problems (stomach ulcer)
more prevalent than in general population


What are some treatments for PTSD?

- Watchful waiting in mild/moderate PTSD for first

- Pharmacotherapy
- Mirtazapine, paroxetine, sertraline, olanzapine

- Psychological interventions
- No evidence of benefit of single session debriefing
- Trauma focussed CBT
- Eye movement desensitization and reprocessing


Describe PTSD Management

- Severe PTSD - engagement problems

- Ongoing evaluation of risk to self and others

- Treat comorbidity (substance misuse)

- Physical health checks

- Social support

- Voluntary week/employment

- Carer's assessment


What is the prognosis of PTSD?

- 56% improve after receiving psychotherapy (no
longer meeting diagnostic criteria for PTSD)

- 38% continue to have some residual symptoms

- Highest remission rates in PTSD survivors of natural
disasters 60%

- Trauma severity, the lack of social support and
additional post-trauma life stressors important rrisk


What are the problems with the current DSM diagnostic classification of PTSD?

- Complex PTSD (Herman, 1992)

- Disorder of extreme stress, not otherwise specified,
DESNOS (Van der Kolk et al. 1996)

- Enduring personality change after catastrophic
experience, EPCACE (ICD 10)


What is Enduring Personality Change After Catastrophic Experience EPCACE?

- a change of at least four years duration in a
person's pattern of perceiving, relating to, or thinking about the environment and self following exposure to catastrophic stress


What are the main features of EPCACE?

- Permanent hostile and distrustful attitude

- Social withdrawal

- A constant feeling of emptiness and/or hopelessness (may be associated with increased dependency on others, prolonged depressive mood without evidence of depressive disorder before trauma)

- Feeling of being ‘on edge’ or threatened

- Permanent feeling of being changed or different to others


What are some conditions for EPCACE?

- No history of existing personality pathology prior
traumatic experience

- May or may not be preceded by PTSD

- Not related to other mental health disorders or
organic brain injury


What is the aetiology of EPCACE?

- Catastrophic trauma


What is Catastrophic trauma?

- catastrophic trauma would involve prolonged exposure to life-threatening circumstances with imminent possibility of being killed (for example exposure to war trauma, concentration camp experience, being tortured, hostage situations and sexual assault)


What is PTSD according to ICD-11?

- PTSD – three clusters of symptoms

- Complex PTSD introduced as a new
diagnostic category


What is complex PTSD (ICD-2018)

- Exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (torture, slavery, genocide campaigns, prolonged domestic violence,
repeated childhood sexual or physical abuse)


What are other features of Complex PTSD?

- Problems with affect regulation

- Feelings of worthlessness, shame and guilt

- Difficulties with sustaining relationships


What are the problems with the definition of Complex PTSD?

- CPTSD criteria overlap with criteria for PD –
this could lead to diagnostic confusion both
clinically and in research

- Risk factors (sexual and physical abuse)- the
same for CPTSD and PD

- ?preference for CPTSD - Stigma attached to
PD diagnosis

- ?treatment for CPTSD vs treatment for PD


What is the ICD 11 criteria of harmful substance use?

- Damage to mental or physical health of the user in absence of Dx of dependence syndrome

- Damage observed over 12 months if episodic use, one month if continuous use

- Harm due to one or more of the following:
- behaviour related to intoxication;
- direct or secondary toxic effects on body organs and systems
- or a harmful route of administration.


What is dependence?

- Sense of compulsion

- Difficulty in controlling (onset/termination/level of use, all-or-nothing

- Withdrawal state (physical/cognitive state)

- Tolerance

- Progressive neglect despite harmful consequences

- DSM V: Abuse and dependence combined to single disorder, added gambling


What increases dopamine levels in ventral striatum (nucleus accumbens)?

- Food

- Sex

- Drugs e.g. cocaine, amphetamine, alcohol, MDMA


How does cocaine work?

- Blocks dopamine transporter

- Increases dopamine signalling


How does amphetamine?

- Blocks dopamine transporter

- Enhances dopamine release