What precipates development of post-traumatic stress disorder (PTSD)?
Exposure to actual or threatened death, injury, or sexual violence. The patient may have either been directly subjected or merely witnessed/learned of the incident.
What is an intrusion? Give a few examples of how they can manifest.
What can provoke an intrusion?
An intrusion is the re-experiencing of a traumatic event, these can manifest both consciously or in dreams. Dissociative reactions may be seen (actively reliving, unaware of the present).
Internal or external cues (triggers) provoke the distress.
What is avoidance in the context of PTSD?
How can this harm the patient?
Avoidance of anything that can trigger an intrusion; memories, thoughts, feelings concerning the event, as well as people, places, conversations, etc regarding it.
Will lead to withdrawal, detachment, persistent negative emotional states. Patients may develop distorted cognitions about the event or pessimistic beliefs about themselves or the world.
Patients with PTSD may exhibit symptoms of hyperarousal. Name 5-6 manifestations of hyperarousal.
1. Sleep disturbance
2. Irritability or outbursts
3. Difficulty concentration
5. Exaggerated startle response
6. Reckless or self-destructive behaviors
According to the Horowitz theory of Integration, what can result from imbalanced management of post-traumatic stress?
Undercontrol (ignoring the stress, etc) leads to more intrusions.
Overcontrol (excessive avoidance, denial, etc) leads to negative alterations in mood & cognition.
How long must PTSD be experienced for a diagnosis?
Does it affect men or women more?
What occupations are at highest risk?
At least 1 month.
Women (men may be less likely to seek help)
Soldiers, law enforcement, firefighters, EMS, disaster workers.
What role does the amygdala play in the development of PTSD?
Neuroanatomy: Review the sites of amygdalar input & output, and recall 3 structures it may signal to.
The amygdala controls fear responses & anxiety, and can control physiologic & behavioral outputs without cortical processing.
Input through the lateral amygdala, output through the central amygdala to the central gray ("freeze response"), lateral hypothalamus (ANS outflow, BP), and paraventricular nucleus (hormone release)
What role does the hippocampus play in PTSD?
What change occurs in the disease?
The hippocampus contextualizes fear to regulate it on the basis of your current situation. (eg a lion at the zoo is fascinating, but on the savannah invokes fear).
Hippocampal volume decreases in PTSD; thus, it is harder to contextualize stressors, and innocuous triggers may cause a fear response.
What role does the prefrontal cortex play in PTSD?
Recall that the frontal lobe is important to executive motor function. Its activation is reciprocal to that of the amygdala.
(So, amygdalar activation can diminish motor function? Harder to express fear?)
According to psychotherapeutic principles, how can traumatic or repressed memories be accessed?
Since memory is state-dependent, put the patient into a high state of physiologic arousal.
What goal is sought in the behavioral treatment of PTSD?
How is this achieved?
Extinction of the fear response to triggers.
Like with other anxiety disorders, therapeutic exposure is key for desensitization. Encourage patients to revisit traumatic memories in a safe or calming setting.
Describe 3 different types of PTSD therapies, and the brain structures they supposedly relate to.
Talk therapy: Lateral prefrontal cortex
CBT: Medial prefrontal cortex & amygdala
Drug: Presumably all, but notably amygdala.
CBT is an effective choice for treating PTSD. Name 3-6 examples.
Stress Inoculation Training
Imagery Rescripting & Reprocesing Therapy
Cognitive Restructuring Within Reliving
Imaginal/In Vivo Exposure
Prolonged Imaginal Exposure
Cognitive Processing Therapy (wat)
What are some questions that are appropriate to screen for PTSD (for a patient who has experienced such an event)
Have you experienced any vivid thoughts about X?
What do you believe is the cause of X?
Are you able to return to the site of X?
What do you think could be done to prevent X?
What is the difference between Type I and Type II trauma? What symptoms are more characteristic of Type II?
Type I refers to a single traumatic event, while Type II is ongoing and chronic (multiple exposures). These patients feature more negative symptoms (depression, sleep disturbance) and loss of memory (must "block out" to function).
Name a few comorbidities seen with PTSD.
Social or specific phobias
Major depressive disorder