Stress & PTSD

Question 1

Define stress

Answer 1

Any situation which requires adjustment, or when a person perceives the demands of a situation to be greater than their ability to cope with that demand. Good stress is eustress, and bad stress is distress.

Question 2

How is stress adaptive?

Answer 2

Small amounts of eustress motivates adaptation reaction to the environment.

Question 3

What are the long term consequences of prolonged stress?

Answer 3

The biological cost of adapting to stress is the allostatic load. A high, prolonged allostatic load can have detrimental effects on the immune system due to cortisol, making the individual more susceptible to illness. It can also cause chronic high blood pressure, and subsequent cardiovascular issues.

Question 4

What factors predispose a person to stress?

Answer 4

• Children are particularly vulnerable to severe stressors such as war and terrorism.
• Adolescents with depressed parents are more sensitive to stressful events, and are more likely to respond to stressful events with depression.
• Early stressors can have a cumulative effect, making us more sensitive to stress later on (Johnson et al. 2002 found that rats exposed to tail shocks produced more cortisol when exposed to another stressful situation later).
• Cognitive appraisal: depressed people perceive events as more stressful than non-depressed people (Havermans et al. 2007).

Question 5

What are the six dimensions of stressors?

Answer 5

1. The severity.
2. The chronicity.
3. Its timing.
4. How closely it affects our own lives.
5. How expected it is.
6. How controllable it is.

Question 6

What factors make someone more resilient to stress?

Answer 6

• Being male.
• Being older.
• Being well educated.
• More economic resources.
• High self confidence.
• Positivity (people who can still show genuine positive emotions when talking about loss tend to cope better with bereavement (Bonnano et al. 2011).

Question 7

Outline the sympathetic-adrenomedullary system’s response to stressors.

Answer 7

SAM prepares fight-or-flight. Begins in the hypothalamus, stimulating the SNS, causing the adrenal medulla to secrete adrenaline and noradrenaline.

Question 8

Outline the hypothalamus-pituitary-adrenal axis’ response to stress

Answer 8

The hypothalamus releases CRH, stimulating the pituitary gland to release ACTH, inducing the adrenal cortex to produce glucocorticoids (cortisol in humans).

Question 9

Outline the criteria for Post-traumatic Stress Disorder

Answer 9

• A. Exposure to actual/threatened death/serious injury/sexual violence through direct experience/witnessing/occuring to a close family member or friend (for death, must be violent or accidental)/repeated and extreme exposure to aversive details of traumatic events (e.g. first responders collecting human remains, not through media unless work related).
• B. One or more intrusion symptoms
  
  • recurrent/involuntary/intrusive memories
  • recurrent/distressing dreams
  • dissociative reactions
  • triggers (with marked physiological and psychological reaction to these triggers).
• C. Persistent avoidance of associated stimuli.
• D. Negative alterations in cognitions and mood associated with traumatic event.
• E. Marked alterations in arousal and reactivity.

Question 10

What 4 areas are clinical symptoms of PTSD grouped into?

Answer 10

• Intrusion.
• Avoidance
• Negative cognitions and mood.
• Arousal and reactivity.

Question 11

Compare rates of PTSD for trauma with human intent to trauma without. Compare rates of PTSD for direct trauma to indirect trauma.

Answer 11

• Whether the trauma had human intent (Shalev and Freedman, 2005, compared PTSD rates after car accidents and terrorist attacks in the same Israeli community. No difference at 1 week, significantly higher for terrorist attack survivors at 4 months.
• Direct exposure (Neria, Nandi and Galea, 2008) estimate that PTSD rates were between 30-40% of adults directly exposed to disasters, the prevalence in rescue workers tends to be lower (5-10%).

Question 12

What is the function of cortisol? What is the problem of prolonged cortisol secretion?

Answer 12

• Cortisol prepares the body for fight-or-flight, inhibiting the immune response.
• Prolonged cortisol can damage brain cells, particularly in the hippocampus. Stressed babies “fail to thrive”.

Question 13

Why may someone be more at risk of experiencing a traumatic event? Compare this to the factors increasing the likelihood of developing PTSD given a traumatic event.

Answer 13

More risk:

• Occupation (e.g. soldiers, fire fighters).
• Being male.
• Less than college education.
• Conduct problems in childhood.
• Family history of psychiatric disorder.
• High extraversion and neuroticism scores.
• Race, i.e. Black Americans compared to White Americans.

Given exposure to a traumatic event, risk factors for developing PTSD include:

• Being female.
• Low social support.
• Neuroticism.
• Pre-existing problems with depression and anxiety.
• Family history of depression, anxiety, and substance abuse.
• Cognitive appraisals of their own stress symptoms after trauma (e.g. feeling weak or ashamed for experiencing symptoms).

Question 14

How may cognitive ability provide a buffer against PTSD?

Answer 14

They may be able to create meaning from traumatic experience and create a personal narrative of some kind.

Question 15

What are the physical and psychological effects of PTSD on memory?

Answer 15

• The more the traumatic event is brought to conscious awareness and recalled, the less accurate the memory (Moradi et al. 2008).
• Prolonged glutocorticoid exposure can induce PTSD-like memory impairments in mice (Kaouane et al. 2012).
• Cortisol promotes neural degradation- in severe trauma patients, esp. those with PTSD- the medial prefrontal cortex was volumetrically smaller in size than normal and hyporesponsive in cognitive tasks- MPFC linked with emotional responsiveness and conditioned fear response (McNally, 2006).
• As sleep promotes memory consolidation, the insomnia seen in PTSD sufferers can produce memory impairments, such as an impaired ability to remember extinction of conditioned fear (Pace-Schott, Germain, and Milad, 2015).

Question 16

Outline the biological factors in developing PTSD (gender, gene*environment interactions, brain abnormalities).

Answer 16

Gender.

• Women with PTSD have higher levels of cortisol than women without. Men do not seem to differ. Levels of cortisol tend to be lower in people with PTSD who have experienced physical or sexual abuse. I.e. type of trauma seems to be an important factor.

Gene*environment interactions.

• As well as stress, the 5HTTLPR gene has been implicated in post-hurricane PTSD; those with the s/s phenotype were at higher risk of PTSD IF they also had high hurricane exposure and low social support. Also more likely to develop depression.

Brain abnormalities:

• Reduction in hippocampal volume. Gilbertson et al (2002) measured hippocampal size in combat veterans both with and without PTSD who were also MZ twins. In the healthy co-twins of combat veterans with PTSD, they also had small hippocampal volumes. Combat veterans without PTSD, as well as their twins, had similar and larger hippocampal volumes. This suggests, for reasons not understood, that small hippocampal volume may be a vulnerability factor for developing PTSD in those exposed to trauma. o
• However, also found in depressed people. PTSD and depression are highly comorbid, difficult to disentangle brain abnormalities specific to PTSD.

Question 17

Outline the sociocultural factors for developing PTSD.

Answer 17

Membership of a minority group.

• Studies after 9/11 found 15% overall prevalence of PTSD in direct survivors 2-3 years after. African American and Hispanic survivors were more likely to have PTSD than White survivors. Explain with education and income having an impact on resilience.

Return to a negative and unsupportive social environment.

• Merbaum (1977) found in a 1-year follow up of male Israeli war casualties with psychiatric illness continued to show extreme anxiety, depression and physical complaints which worsened with time. Hypothesised that this was due to the negative attitudes of the community due to their reliance on their army’s strength, and stigma against those who psychologically break down in combat.
  
  • To improve morale in combat, can provide breaks from long engagements with “safe zones” which include improvements such as air conditioning, regular mail delivery, good food, and internet access.

Question 18

How can PTSD be prevented?

Answer 18

• While impossible to prevent trauma entirely, efforts need to made in order to reduce trauma from things such as school shooting with increased firearm control.
• Possible to prevent maladaptive responses to stress by preparing people in advance, providing them with information and coping skills, especially in at-risk occupations.
• The use of cognitive-behavioural techniques, such as stress-inoculation training, prepares people to tolerate an anticipated threat by changing their appraisals before or during a stressful event.

Question 19

How can PTSD be treated? (hotlines, intervention, debriefing, medication, CBT, negative appraisal modification). What happened after WTC w/ psychologists- i.e. people “getting over it”?

Answer 19

Many people recover without professional help.

• After the terrorist attacks at the WTC, grief and crisis counsellors flocked to NYC in the expectation that vast amounts of psychological assistance would be required.
  
  • However, relatively few people sought this help, and the millions of dollars allocated to cover the costs of treatment went unspent. It is quite typical, with the help of friends and family, for traumatised people to recover naturally.
• Telephone Hotlines: often staffed with volunteers who need to show empathy and respect for callers.
• Crisis Intervention is of brief duration and focuses on the immediate problems that the individual or family faces after trauma. Assumes that the individual functioned psychologically well before trauma. The therapist needs to act quickly, clarifying the problem, suggesting plans of action, providing reassurance, information, and support.
  
  • In a single-session, earthquake trauma victims display lower fears and an increased sense of control over their feelings (Basoglu et al. 2007). Also receive knowledge and skills to help them in the coming weeks and months.
• Psychological Debriefing: designed to help and speed up the healing process in people exposed to trauma. Encouraged to discuss their experience in a structured environment in order to normalise common reactions to trauma.
  
  • Belief that psychological debriefing should be mandated for disaster victims.
  • One form is Critical Incident Stress Debriefing, lasting between 3 and 4 hours in a group format, usually 2-10 days after a “critical incident” or trauma.
  • However, little evidence to support clinical effectiveness, despite reports of satisfaction with procedure.
  • Most beneficial approaches focus on allowing the client to take the lead in determining who to talk to and how to talk. Therapists should engage in active listening, being supportive but without directing and pushing the client for information.
• Medication, such as antidepressants are sometimes helpful in alleviating PTSD symptoms of depression, intrusion, and avoidance (Reinecke et al. 2007).
  
  • Antipsychotics can also be used.
• Cognitive-Behavioural Treatments. One behaviourally-oriented treatment strategy is prolonged exposure. The patient is asked to vividly recount the traumatic event over and over until there is a decrease in his or her emotional responses. Involves repeated or extended exposure (either in vivo or imagined) to feared (but objectively harmless) stimuli.
  
  • May be difficult in traumatised individuals with extreme issues with trust, need an especially capable and caring therapist. Has been shown to be effective- leads to a reduction of symptoms in women who served in the military. However, there are high drop-out rates.
• Relaxation training may also help.
• Cognitive approaches based around reducing negative appraisals common in PTSD. Designed to modify these appraisals to reduce the threat the patient experiences in their memories of the traumatic event, and remove problematic cognitive and behavioural strategies.
  
  • Evidence suggests this to be very effective with a very low drop-out rate, with treatment gains appearing after treatment ended.