Response to traumatic stress

Question 1

What is type 1 trauma?

Answer 1

Single incident trauma, unexpected

Question 2

What is type 2 trauma?

Answer 2

Repetitive trauma
Ongoing abuse, hostage taking, genocide
Betrayal of trust in a primary care-giving relationship 
Developmental trauma
Attachment/ attunement disruption

Question 3

What is the importance of trauma in chronic depression?

Answer 3

A history of early life trauma in chronic depression predicts the need for psychotherapy as an adjunct to pharmacotherapy

Question 4

What is the importance of trauma in bipolar disorder?

Answer 4

High percentage have a history of childhood deprivation or abuse

Question 5

What are the impacts of anxiety and fear in a traumatic situation?

Answer 5

Freeze
Flee
All originate in PAG or ventral tegmental area

Question 6

What is the freeze response?

Answer 6

If distant threat; voluntary

When inescapable threat; tonic immobility occurs which is an involuntary state of profound motor inhibition

Question 7

In what areas of trauma is the freeze response most common?

Answer 7

Direct physical contact with predator/ aggressor

Question 8

What is tonic immobility?

Answer 8

Decreased vocalisation 
Intermittent eye contact
Rigidity and paralysis
Muscle tremors in extremities
Chills
Unresponsive to pain

Question 9

Why does tonic immobility enhance survival?

Answer 9

Predators less likely to attach immobile pain
If attacked, immobility may cause them to loosen grip increasing the changes of escape
Decreased risk of extreme violence which fighting back can cause
Some will lose interest if victim immobile and unresponsive

Question 10

Very simplified neurobiology of threat?

Answer 10

Increased proximity to a predator shits brain activation from prefrontal cortex to the midbrain superior colliculi and PAG

Question 11

What is the action of cortisol on the brain?

Answer 11

Acts as a negative feedback on the pituitary, hypothalamus, hippocampus and amygdala

Question 12

Are cortisol levels high or low in PTSD?

Answer 12

Low

Question 13

What is the DCM criteria for a traumatic event?

Answer 13

Experiences, witnessed or confronted; induces indirect exposure
Threat of death or serious injury

Question 14

What is the ICD-10 criteria for a traumatic event?

Answer 14

Delayed or protracted response
Exceptionally life threatening or catastrophic
Likely to cause pervasive distress in almost anyone

Question 15

What are environmental risk factors for PTSD?

Answer 15

Lack of support network
Ongoing life stresses
Reactions of others
Economic resources
Disadvantage 
Displacement

Question 16

Normal reactions to trauma?

Answer 16

Numbness, shock, denial
Fear
Depression or elation
Anger, irritability
Guilt
Impaired sleep
Hopelessness, helplessness
Perceptual changes
Avoidance
Intrusive experiences
Hyperarousal, hypervigilance

Question 17

What are common psychological reactions after trauma?

Answer 17

Depression 
Grief reactions
Panic attacks +/- agoraphobia
Alcohol/ drug dependence
Brief hypomania
Specific phobias

Question 18

What are common co-morbid psychiatric conditions that occur in 80% of patients with PTSD?

Answer 18

Depression
Drug and alcohol abuse
Anxiety disorders

Question 19

What is intrusive phenomena?

Answer 19

Recurrent distressing recollections
Nightmares; particularly in PTSD
Flashbacks; visual , auditory, taste, smell, tactile 
Distress accompanying reminders
Physiological reactions (freeze or flee)

Question 20

What are avoidant and emotional numbing symptoms?

Answer 20

Avoidance of thinking or talking about the event
Avoidance of reminders such as activities, places or people
Amnesia for important aspect of trauma
Loss of interest in activities
Detachment
Emotional numbing
Sense of foreshortened future

Question 21

Hyperarousal symptoms?

Answer 21

Sleep disturbance
Irritability/ anger
Concentration difficulties
Hypervigilance
Exaggerated startle response

Question 22

What is complex PTSD?

Answer 22

PTSD symptoms along with; 
Cognitive disturbance; low self-esteem, self-blame, hopelessness, helplessness, preoccupation with threat 
Identity disturbance
Emotional dysregulation 
Chronic interpersonal difficulties
Dissociation 
Somatisation 
Tension reduction activities; binge-purging, self mutiation, substance misuse

Question 23

What is the triune brain theory?

Answer 23

Mammalian brain (or limbic system): emotional and somatosensory memory, attachment
Frontal cortex: regulatory activities, cognitive and executive function 
Reptilian brain; autonomic arousal, instinctive responses

Question 24

Which areas of the brain are of interest in PTSD?

Answer 24

Hippocampus (role in memory and stress response)

Amygdala (role of fear both ni trauma and itr recollection)

Question 25

What is the correlation between the hippocampus and PTSD?

Answer 25

Size of hippocampus correlates with the severity of PTSD

Question 26

What conditions are low hippocampal volume associated with?

Answer 26

Bipolar disorder
Aging preceding dementia
Dementia
Cushing's syndrome
Alcohol misuse
Borderline personality disorder

Question 27

Summary of the neurobiology behind fear and PTSD?

Answer 27

Under threat; activity shifts to PAG 
Hippocampal atrophy 
Increased activity of amygdala and other limbic activities
Deactivation of broca's area 
Right-hemispheric lateralisation

Question 28

What is the aim of treatment in PTSD?

Answer 28

Normalise reactions
Enable catharsis
Inspire hope, restore sense of safety +/- trust
Treat core symptoms and comorbidity
Limit kindling of symptoms
Educate

Question 29

Which psychological therapies have been shown to have an effect in PTSD?

Answer 29

CBT

EMDR (Eye Movement Desensitisation and Reprocessing)

Question 30

How many sessions are recommended for PTSD?

Answer 30

12

Question 31

Which medications are recommended as a 2nd line in PTSD treatment?

Answer 31

Paroxetine
Citalopram 
Mirtazapine 
Prazosin (nightmares) 
Mood stabilisers
Risperidone