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Trauma and stress-related

disorders
2018
DSM5
Reactive attachment Disorder (child)
Disinhibited Social Engagement
Disorder(child)
Acute stress Disorder
PTSD
Adjustments Disorders
Anxiety and Memory disorder

PTSD
Pathophysiology of PTSD

 The amygdala is the key structure implicated in PTSD.

 Exposure to traumatic stimuli can lead to fear conditioning,


with resultant activation of the amygdala and associated
structures, and disruption of inhibitory feedback from the
cortex and the hippocampus

 Accompanying autonomic neurotransmitter and endocrine


activity produce many of the symptoms of PTSD.
Fear Conditioning=Classical Conditioning
Brain structures involved in dealing with
fear and anxiety
The Essential feature of PTSD

Is the development of the characteristic


symptoms following exposure to traumatic
events. Symptoms start typically within a
month from exposure.
A. Exposure to actual or threatened
death, serious injury, or sexual violence
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to
others.
3. Learning that the traumatic event(s) occurred to a
close family member or close friend. In cases of actual
or threatened death of family member or friend, the
event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to
aversive details of the traumatic event(s) (e.g., first
responders collecting human remains; police officers
repeatedly exposed to details of child abuse).
 0ne or more of above
Causes
serious road accidents
violent personal assaults, such as sexual assault,
mugging or robbery
sexual abuse, violence or severe neglect
witnessing violent deaths
military combat
being held hostage
terrorist attacks
natural disasters, such as severe floods,
earthquakes or tsunamis
a diagnosis of a life-threatening condition
an unexpected severe injury or death of a close
family member or friend
B. Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing
memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content
and/or affect of the dream are related to the traumatic
event(s).
3. Dissociative reactions (e.g., flashbacks) in which the
individual feels or acts as if the traumatic event(s) were
recurring. (Such reactions may occur on a continuum, with
the most extreme expression being a complete loss of
awareness of present surroundings.)
4. Intense or prolonged psychological distress at exposure
to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external
cues that symbolize or resemble an aspect of the
traumatic event(s).
C. Persistent avoidance
1. Avoidance of/ efforts to avoid distressing
memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external


reminders (people, places, conversations,
activities, objects, situations) that arouse
distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s).
 one or both symptoms
D. Negative alterations in cognition and mood (2 or more S.)
 1. Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs).
 2. Persistent and exaggerated negative beliefs or expectations
about oneself, others, or the world (e.g., “I am bad,” “No one
can be trusted,” “The world is completely dangerous,” “My whole
nervous system is permanently ruined”).
 3. Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the individual
to blame himself/herself or others.
 4. Persistent negative emotion state (e.g., fear, horror, anger,
guilt, or shame).
 5. Markedly diminished interest or participation in significant
activities.
 6. Feelings of detachment or estrangement from others.
 7. Persistent inability to experience positive emotions
E. Marked alterations in
arousal and reactivity

 1. Irritable behavior and angry outbursts (with little


or no provocation) typically expressed as verbal or
physical aggression toward people or objects.
 2. Reckless or self-destructive behavior.
 3. Hypervigilance.
 4. Exaggerated startle response.
 5. Problems with concentration.
 6. Sleep disturbance (e.g., difficulty falling or
staying asleep or restless sleep).
 Two or more symptoms
Duration and impact
 F. Duration of the disturbance (Criteria B, C, D, and E) is
more than 1 month.
 G. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
 H. The disturbance is not attributable to the physiological
effects of a substance (e.g., medication, alcohol) or another
medical condition.
Specifier: Dissociative symptoms

Depersonalization
Detachment
Feeling of sense of unreality of self
Time moving slowly

Derealization
World is unreal, dreamlike, distorted
Specifier : Delayed expression
Full diagnostic criteria are not met until at
least 6 months after the event although
onset and some symptoms may be
immediate.
Comorbidities
 PTSD patients are 80% more likely to meet criteria for
at least one other mental disorder.

Suicidality
Psychosis
Substance abuse
Family dysfunction
Homelessness
CVD
Premature aging
Type II DM
 ……
Risk and Protective Factors for PTSD
WWI Trenches (Shell Shock)
The experience of War

 Miguel Centeno : The Paradoxes of War ( week 4)

 Shell schock 1918 film : https://youtu.be/r__bkujt6T4


Risk factors
 Characteristics of the trauma exposure itself
 Proximity
 Severity
 Duration of exposure
 Characteristics of the individual
 Prior trauma exposures
 Family history or personal prior psychiatric illness
 Gender (women are at greatest risk for many of the most common assertive
traumas).
 Post-trauma factors
 Availability of social support
 Emergence of avoidance or numbing
 Hyperarousal, and re-experiencing symptoms

 Approximately 30% of men and women who have spent time in a war zone
experience PTSD.
Pre-traumatic Factors
Temperamental: childhood trauma , anxiety or
externalizing

Environmental : low SE, low education, low


intelligence, childhood adversity, cultural
characteristics, self-blaming strategies,; minority
status, family psychiatric history. Social Support prior
to exposure is protective.

Genetic and physiological : Female, young and


possible genetic link
Peri-traumatic Factors

Severity of trauma
Trauma perpetrated by a caregiver
For military personnel : being a perpetrator,
witnessing atrocities
Dissociation during the trauma
Post-traumatic factors
Temperamental:
Negative appraisals, poor coping

Environmental :
Exposure to repeated upsetting reminders,
subsequent adverse life events, financial and
other trauma- related losses.

Social support in this phase moderates outcome


Biological Disturbances
Patients with PTSD have abnormal HPA
function as compared to patients without
PTSD and have a much greater variation in
their levels of adrenocorticoids.
Pharmacological Treatment
Fear, anxiety and depression
First line treatment : SSRI
Paroxetine 20-50 mg daily
Sertraline up to 200 mg daily
Fluoxetine 20-60 mg daily
MAOI : Phenelzine 30-45 mg daily

Atypical Antipsychotics

Nightmares and disturbances in arousal during the day


 Prazosin: Noradrenergic blockade alpha-1 post-synaptic
receptor
Non-Pharmacological treatment
 Befriending the emotional brain

 Dealing with hyperarousal ( Yoga, Movement, Rhythm)


 No Mind without Mindfulness
 Group work : Relationship wiring of brain circuits is devoted to
being in tune with one another
 Communal rhythm and Synchrony
 Getting in Touch
 Taking Action

 Integrating traumatic memories


 Desensitization
 Eye Movement Desensitization and Reprocessing (EMDR)
 Deep Brain Stimulation (DBS)
EMDR points
 Loosening up of a complex in the mind/brain that gives people
rapid access to loosely associated memories and images from
their past.

 This allows the traumatic experience to be placed into a larger


context or perspective

 People may be able to heal from trauma without talking about it

 EMDR can help even if the patient and therapist do not have a
trusting relationship
EMDR in Trauma: Eye Movement
Desensitization and Reprocessing

Van der Kolk p.250


Efficacy of EMDR
 Chen et al, 2014
Meta-analysis of 26 RCT of EMDR published
between 1991 and 2013.
Results :
1. EMDR significantly reduced
Symptoms of PTSD
Depression
Anxiety
Subjective distress
2. Session duration of > 60 minutes major
contributing factor to amelioration
3. Therapist experienced in group therapy for
PTSD significant contributing factor
Prognosis of PTSD
 Difficult to determine : varies significantly from patient to patient.
 Some individuals who do not receive care gradually recover over a
period of years.
 Many individuals who receive appropriate medical and psychiatric
care recover completely (or nearly completely).
 Rarely, even with intensive intervention, some individuals
experience worsening symptoms and commit suicide.

 In patients with PTSD who are receiving treatment, the average


duration of symptoms is 36 months, compared with 64 months for
those patients who do not receive treatment. However, more than one
third of patients who have PTSD never fully recover.

 Factors associated with a good prognosis include rapid engagement


of treatment, early and ongoing social support, avoidance of re-
traumatization, positive premorbid function, and an absence of other
psychiatric disorders or substance abuse.
Adjustment Disorders
Adjustment

 A stressor
 An individual
 An outcome
Characteristics of the Stressor

 Severity
 Duration and repetitiveness
 Nature of the stressor
 Symbolic meaning of the stressor
Personal Characteristics
 Past history, current circumstances, future expectations
 Personality Pattern
 Coping strategies
 Conscious, intentional, adaptive
 Defense Mechanisms
 Unconscious, unintentional, potentially maladaptive
 Resilience
Prevalence of Childhood Adversity

 ACE ( Adverse Childhood Experiences) study: (19-92)


Family related adversity
 64% of respondents: at least one adverse childhood experience
( physical abuse, parental substance abuse, sexual abuse,
parental mental illness, witnessing violence against one’s
mother…etc.)

 U.S National Comorbidity Study (18-54)


Exposure to man-made disasters
 9.3% of respondents (accidents, traumatic episodes, being
mugged or kidnapped)

Evidence of Clustering of adverse events


Psychological and Physical Health
Outcomes of Childhood Adversity
 Major depression, Suicidal behavior, Anxiety disorders
 Substance use and abuse, Disorders involving aggression
( Afifi 2008, Anda, 2006, Keesler 19997, MacMillan 2001….)

 Sleep disorders, Severe obesity, Smoking, COPD, IHD


 Use of prescription drugs, Chronic pain
 Chronic fatigue Syndrome
(ACE study publications)

ACE : dose response relation of family-related childhood


adversities to long-term mental and physical health outcomes.
Neurobiological pathways childhood
adversity (CA) causing later pathology
 Changes in the structure and function of the hippocampus
and frontal cortex ( animal models, abused children and
adults with PTSD)

 Impairment of the physiological stress response

 Both low SE status in childhood ( independent of current


status) AND a long allele of the serotonin transporter gene -
promoter ( 5-HTTLPR) : exaggerated cardiovascular
reactivity to mental distress in adulthood.

 Parental death in childhood : higher BP and elevated daily


stress hormones in adulthood.
Resilience
 Definition : outcome of successful adaptation to adversity

 2 fundamental questions:
 Recovery: how well people bounce back and recover from a
challenge
 Sustainability: how well do people sustain health and physical
wellbeing in a dynamic and challenging environment
Adjustment disorder

 The symptoms are a result of the coping style and defenses

 The symptoms are a result of failure of coping


Acute Stress Disorder (ASD)
vs. Adjustment Disorder (AD)
 1. Timing
 AD. Can be diagnosed immediately after exposure and last up to
6 months- it can become chronic
 ASD Between 3 days and 1 month after exposure
 2. Symptom Profile

 Special Considerations:
 Following a trauma of the type that causes ASD and PTSD a
patient may develop symptoms of AD- diagnose AD
 When no identifiable traumatic event has occurred but the patient
presents with symptoms of ASD or PTSD –diagnose AD.
The internal experience of
Adjustment Disorders
Affective states
An overriding affective feature is a vague
uneasiness resulting from the new event:
uncertainty, apprehensiveness..
Cognitive patterns
Focus on the situation or avoid it
Focus on the emotional state or on the
problem
Somatic conditions
A general state of tension and apprehension
Relationship patterns
Increased expressions of dependency
Distancing from relationships (
shame/neediness)
The crucial questions

What is the patient having trouble adjusting


to ? ( Black & Andreasen)

Why is the patient having trouble adjusting


to this particular stressor?

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