Responses to Traumatic Stress

Question 1

Classifications of traumatic events?

Answer 1

Intention (assault, robbery, rape) VS unintentional (RTA, industrial accident)

Human-made (technological, train/plane crash) VS natural (hurricane, tornado, earthquake, flood)

Centrifugal (affects people who were together only at the moment of the disaster, like in a train/plane crash) VS centripetal (affects an existing community, like a hurricane, tornado, earthquake, flood)

Question 2

Types of trauma?

Answer 2

Type 1 trauma - single incident trauma that was unexpected

Type 2 trauma (AKA complex trauma) - repetitive, e.g: ongoing abuse, hostage-taking, genocide; 3x more likely to cause PTSD than type 1

Question 3

Major factors in type 2 trauma?

Answer 3

Betrayal of trust in the primary care-giving relationship:
• Developmental trauma
• Attachment / attunement disruption

Question 4

Define a major incident?

Answer 4

Any situation assoc. with multiple casualties, fatalities and damage to property, due to natural or unnatural causes, that is beyond what can be coped with, ordinarily, by the deployment of emergency services

Question 5

Reaction to a major incident?

Answer 5

Most people behave individually; few panic or show passive/dazed reactions

Question 6

Uses of media in major incidents?

Answer 6

No research on whether they are helpful:
• May inform communities on how to respond
• Sensationalism, insensitive
• Media moves on to next story quickly

Question 7

Problems that arise when the media does not move on to the next event?

Answer 7

New disasters are not covered, leading to people feeling marginalised and less funds being raised for relief

Question 8

Affect of early life trauma on treatment of chronic depression?

Answer 8

Hx of early-life trauma predicts the need for psychotherapy as an adjunct to pharmacotherapy, i.e: more treatment required

Question 9

Physical health issues that result from exposure to trauma, not inc. physical injury?

Answer 9

Health care utilisation

Infection, pain disorders, hypertension, DM, asthma, allergies

Question 10

Physical health issues that occur due to PTSD?

Answer 10

Excess all-cause mortality

Chronic disease, inc. CV, digestive (inc. liver), MSK, endocrine, respiratory

Even when other factor are controlled, e.g: alcohol and drugs, there are still issues

Question 11

Causes of anxiety and fear?

Answer 11

Genetically ingrained function of the NS that has adaptive evolutionary significant and promotes survival; it is not a sign of weakness

Question 12

Response to anxiety and fear?

Answer 12

Emotion arises from neural processes, originating in the periaqueductal grey (PAG) or ventral tegmental area, that prompt us to:
• Freeze (when the threat is distant or inescapable)
OR
• Flee (when the threat is nearby and escapable)
THESE RESPONSES ARE NOT A CHOICE

NOTE - this is more than fight or flight (which implies a choice)

Question 13

When does a freeze response occur?

Answer 13

To a distant threat (this can be voluntary), i.e: stop, watch and listen pattern of vigilance

When the threat is inescapable, tonic immobility occurs (an involuntary state of profound, but reversible, motor inhibition)

Question 14

When is the freeze response more likely to occur when the threat is inescapable?

Answer 14

When there is direct physical contact with the predator / aggressor

Question 15

Features of tonic immobility?

Answer 15

Decreased vocalisation (do not speak but make guttural noises)

Intermittent EC

Rigidity and paralysis; muscle tremor in extremities

Chills

Unresponsiveness to pain; may be assoc. with peri-traumatic dissociation

Question 16

How does tonic immobility, a seemingly unhelpful response to danger, enhance survival?

Answer 16

There is evidence that predators are less likely to attack

If attack, immobility may cause loosening of grip and increased chance of escape

Decreased risk of extreme violence, assoc. with fighting back

Some attackers lose interest if victim immobile and unresponsive

Question 17

Types of freeze response?

Answer 17

• Frozen fight
• Frozen flight
• Frozen attach
• Frozen hide
• Attentive freeze (broad field)
• Attention freeze (narrow field)
• Tonic immobility
• Low arousal freeze

Question 18

Steps in orienting a response to danger?

Answer 18

1. Arousal - unfamiliar stimulus registers in the NS
2. Arrest - pause / slowing of movement and activity
3. Alert - all sense heightened to take in more info
4. Muscular change - both flexion and extension
5. Orient / scan - search for the location
6. Locate - source of stimulus is found
7. Identify - novelty is registered and/or identified
8. Evaluate - what is it, dangerous / friendly, attention required?
9. Take action:
   • Not dangerous - normal activity resumes
   • Dangerous - defensive or emergency sequence activated
10. Reorganise - NS re-equilibriates

Question 19

Factors affecting orientation of responses?

Answer 19

1. Nature of the stimulus, e.g: abrupt / gradual, familial / unfamiliar
2. Internal state of the person, e.g: existing arousal level, LoC, configuration of mental / physical / emotional components
3. Person’s previous experience, esp. part trauma

Question 20

Neurobiology of threat?

Answer 20

Increased proximity to a predator shifts brain activation from prefrontal cortex to the midbrain superior colliculi and PAG, i.e: when under threat, ACTIVITY SHIFTS TO PAG

These regions are responsible for active and passive defense processes

Question 21

Neurobiology of PTSD?

Answer 21

Assoc. with deficiency in top-down modulation of amygdala activation by the prefrontal cortex

Question 22

Explain resilience factors to trauma

Answer 22

Ability to regulate emotional responses to -ve stimuli may be a protective factor, when exposed to trauma

Question 23

3 looping systems inv. with defence activation?

Answer 23

1st loop - midbrain / brainstem origin (PAG and superior colliculi)

2nd loop - mesolimbic-dopamine system

3rd loop - stimulus-response learning system, i.e: structures that hold the learning

Question 24

Explain the mesolimbic-dopamine system

Answer 24

1. Dysphoric seeking - attachment urge painful and with -ve effects; PAG inputs are fear, rage, panic/grief, shame and often occurs in a loud noise, bright light environment
   Inv. an increase in dynorphins and corticotrophin-releasing factor

Seeking attachment - from a warm, secure base and has +ve effects; PAG inputs are care/nurturing, play/joy, sexual desire and often occur in environments with no noise, peaceful, soft lighting
Inv. an increase in oxytocin, prolactin, Mu, opioids

Question 25

Role of cortisol in the stress response?

Answer 25

Acute stress leads to dose-dependent increase in catecholamines and cortisol Cortisol acts to mediate and shut down the stress response Via -ve feedback, it acts on the pituitary, hypothalamus, hippocampus and amygdala (responsible for stimulation of cortisol)

Question 26

Cortisol levels in PTSD?

Answer 26

Cortisol levels are LOW IN PTSD NOTE - acute stress dose increase cortisol levels but the rise in cortisol levels are lowest in PTSD

Question 27

Definitions of a traumatic event?

Answer 27

DSM - experienced, witness or confronted events, where there is a threat of death or serious injury (to self or others); causes feeling of intense fear, helplessness, horror ICD - delayed and/or protected response to an exceptionally threatening or catastrophic event, which was likely to cause pervasive distress to almost anyone

Question 28

Factors affecting risk or resilience?

Answer 28

* Pre-traumatic, peri-traumatic and post-traumatic | * Person related, trauma related and environment related 2

Question 29

Trauma-related risk factors?

Answer 29

Sudden, unexpected events Man-made rather than natural Prolonged exposure Perceived threat to life Grotesque (multiple deaths and/or mutilation) Dose response relationship, i.e: proximity Personally relevant factors, e.g: inv. of a child or identifying with the victim/family

Question 30

Patient-related risk factors?

Answer 30

Severe acute stress reaction Low serum cortisol increasing acutely Family/personal Hx of mental disorder Serious physical injury (patient's perception) Loss of normal daily function Extremes of age Genetic predisposition Epigenetics (transgenerational effects) - evidence than scaring mice can affect genetics for 6 generations of that family Past experience of trauma, esp. childhood trauma Coping styles Profound sense of hopelessness Personality traits, esp. if anxious pre-trauma Behavioural issues Lower educations, intelligence, SE levels Lifestyle

Question 31

Environmental risk factors?

Answer 31

Lack of a support network Ongoing life stresses Reactions of others Lack of economic resources Disadvantage (social, educational, economic) Displacement

Question 32

Pre-traumatic risk factors?

Answer 32

Personal capabilities and capacity, e.g: locus of control (feeling in charge of own fate rather than feeling reliant on others) Past personal experiences, e.g: childhood trauma, substance misuse, psychiatric Hx, disadvantage Environment, e.g: concurrent life stresses, social capital

Question 33

Peri-traumatic risk factors?

Answer 33

Nature of the event, e.g: sudden events, man-made events, prolonged exposure, etc Impact of the event, e.g: perceived threat to life, physical injury, extensive personal loss

Question 34

Post-traumatic risk factors?

Answer 34

Responses to the event Burden consequent to the event

Question 35

Normal reactions to trauma?

Answer 35

``` Numbness, shock, denial Fear Depression or elation Anger, irritability Guilt Impaired sleep Hopelessness, helplessness Perceptual changes Avoidance Intrusive experiences, e.g: flashbacks Hyperarousal, hypervigilance ```

Question 36

Psychological reactions after trauma?

Answer 36

Depression, grief reactions, panic attacks +/- agoraphobia, alcohol / drug dependence, brief hypomania, specific phobias, PTSD

Question 37

Which disorder has the greatest assoc. with suicide?

Answer 37

PTSD has a stronger assoc. with suicide than any other anxiety disorder

Question 38

Occurrence of comorbidities with PTSD?

Answer 38

Most patients with PTSH have ≥1 co-morbid psychiatric conditions; most common are: • Depression • Drug and alcohol abuse • Other anxiety disorders Many patients with PTSD have ≥3 other psychiatric diagnoses NOTE - few patients have only PTSD

Question 39

Consequences of PTSD?

Answer 39

Severe impairment of social functioning Increased likelihood of using primary and secondary healthcare services

Question 40

DSM-V criteria for PTSD?

Answer 40

Traumatic event(s) 1 or more (of 5) intrusive symptoms 1 or both (of 2) avoidance symptoms 1 or more (of 7) of negative alterations in cognition and mood 2 or more of increased arousal Specify whether there are dissociative symptoms Duration of 1 months Distress and impairment in social or occupational functioning

Question 41

Examples of intrusive phenomena?

Answer 41

Recurrent distressing recollections Nightmares Flashbacks, in any modality Distress accompanies the reminders Physiological reactions (fight or flight)

Question 42

Examples of avoidant and emotionally numbing symptoms?

Answer 42

``` • 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 43

Examples of hyperarousal symptoms?

Answer 43

Sleep disturbance Irritability / anger Conc. difficulty Hypervigilance Exaggerated startle response

Question 44

Negative alterations in cognition and mood assoc. with traumatic events, beginning or worsening after the TE?

Answer 44

Persistent and exaggerated -ve beliefs or expectations about oneself, others or the world Persistent, distorted cognitions about the cause or consequences of the TEs that lead the individual to blame themselves Persistent -ve emotional state, e.g: fear, horror, anger, guilt, shame

Question 45

Symptoms that may be assoc. with PTSD?

Answer 45

``` Dissociative symptoms: • Depersonalisation • Derealisation • Awareness of surroundings • Near death OR out of body experiences ``` Survivor's guilt Performance guilt

Question 46

What is the Just World hypothesis?

Answer 46

Belief that we get what we deserve and deserve what we get; there are 3 core beliefs, with the underlying assumption being of justice and fairness: • World as benevolent • World as meaningful • Self as worthy

Question 47

Pre-trauma factors that affect the Just World hypothesis?

Answer 47

Some people hold -ve pre-trauma views of themselves and often believe that the TE confirms their dysfunctional beliefs; having such pre-trauma beliefs is a risk factor for PTSD NOTE - strongly pre-trauma beliefs can act as a buffer to developing PTSD

Question 48

What is complex PTSD?

Answer 48

``` Have PTSD symptoms but may also have: • Cognitive disturbances, e.g: low self-esteem, self-blame, hopelessness, helplessness, pre-occupation with threat • Mood disturbances • Somatisation • Identity disturbance • Emotional dysregulation • Chronic interpersonal difficulties • Dissociation • Tension reduction activities, e.g: binge-purging, self-mutilation, substance misuse ```

Question 49

Basic emotional senses in a mammalian brain and the midbrain areas responsible?

Answer 49

Seeking / desire - ventral tegmental Rage / anger - dorsal PAG Fear / anxiety - ventral and dorsal PAG Lust / sexual urges - ventral and dorsal PAG Care / maternal nurturance - ventral PAG Panic, grief, separation distress - ventral PAG Play / physical social engagement - ventral tegmental

Question 50

Where are defense and orienting responses generated?

Answer 50

Midbrain

Question 51

What type of processing occurs in a mammalian brain?

Answer 51

Top-down processing N

Question 52

What type of processing occurs in a reptilian brain?

Answer 52

Bottom-up processing, i.e: they act on a fear response with physiological mechanisms and it is all about escape; they cannot orientate to other things

Question 53

Areas of the brain of interest in PTSD?

Answer 53

Hippocampus - has a role in declarative or explicit memory and the stress response Amygdala - has a role in fear during both the TE and its recollection

Question 54

Explain the reduction in hippocampal volume following a TE

Answer 54

Bilateral reduction 2. Right-sided reduction with adult trauma 3. Left-sided reduction with childhood trauma, e.g: CSA; there is no difference between early or late childhood abuse These changes are not demonstrated within months of trauma

Question 55

Why is it that high cortisol levels damage the hippocampus, whose volume is reduced in PTSD, but cortisol levels are low in PTSD?

Answer 55

Apparent paradox but a suggested explanation is that cortisol receptors are more sensitive in people with PTSD, at the levels of the pituitary gland

Question 56

Other hippocampal findings in PTSD?

Answer 56

Hippocampal size corresponds to CURRENT SEVERITY of PTSD

Question 57

Other conditions / states assoc. with decreased hippocampal volume?

Answer 57

BPAD (effect disappears if there is a control for childhood abuse) Ageing preceding dementia Dementia Cushing's syndrome Alcohol misuse Borderline personality disorder NOTE - all assoc. with elevated glucocorticoid levels; glucocorticoid-induced atrophy seems to require prolonged / repeated bursts of excess glucocorticoid

Question 58

Broca's area in PTSD?

Answer 58

Receives a decreased cerebral blood flow, so there is deactivation of Broca's area Broca's area has predominance of emotional areas of the brain, over higher cortical areas; PTSD patients have fragmented memories, emotional memory and may experience dissociation

Question 59

What is retained in Alzheimer's disease, with relation to the amygdala?

Answer 59

Remember their personal experience rather than the context of, e.g: an earthquake Impairment of emotional event memory is related to amygdala damage

Question 60

Potential reason for the timeless quality of traumatic memory?

Answer 60

Right-hemispheric lateralisation

Question 61

General principle of treating PTSD?

Answer 61

Ensure safety before starting (managing ongoing trauma, e.g: domestic violence, etc) Drug treatments are not part of routine care; trauma-focused psychotherapy is preferred

Question 62

Aims in treatment of PTSD?

Answer 62

Normalise reactions Enable catharsis and inspire hope, restore sense of safety and trust Treat core symptoms and comorbidities and limit kindling of symptoms Educate patient

Question 63

2 evidence-based psychotherapies?

Answer 63

CBT EMDR (eye movement desensitisation and reprocessing)

Question 64

Treatment of PTSD?

Answer 64

Offer CBT or EMDR, regardless of timelapse since TE; this should last long enough, be regular and with the same therapist NOTE - these are less likely to help in complex PTSD but are useful for single event PTSD Augmentation with medication if there is a failure to respond to the above treatments Non-trauma focused interventions should not be routinely offered Imaginal exposure is recommended but rarely done

Question 65

Treatment of post-traumatic reactions?

Answer 65

1. Stabilisation and resourcing, inc. safety 2. Reprocessing of trauma memories / material 3. Reintegration

Question 66

Drugs used in PTSD treatment?

Answer 66

* Paroxetine * Mirtazapine * Amitriptyline * Phenelzine Alternative - prazosin, atypical anti-psychotics, mood stabilisers (carbamazapine)