Trauma and Stress-Related Disorders

Trauma and Stress-Related Disorders Overview

• Trauma and stress-related disorders are mental health conditions triggered by traumatic or highly stressful life events.
• Such events include combat, sexual assault, accidents, natural disasters, terrorist attacks, and childhood abuse.
• These events lead to maladaptive emotional and behavioral responses, including anxiety, fear, dissociation, avoidance, and hypervigilance.

Post-Traumatic Stress Disorder (PTSD)

• This is a common condition among trauma and stress-related disorders.
• According to DSM-5, diagnosis requires the exhibition of symptoms from four categories for at least one month.

PTSD Symptom Categories

• Intrusive symptoms involve recurrent, involuntary, and distressing memories of the trauma.
• Flashbacks are feelings as if the trauma is recurring, sometimes they can come during nightmares.
• Avoidance symptoms include efforts to avoid thoughts, memories, or conversations about the event.
• Sufferers will avoid people, places, or situations associated with the trauma.
• Emotional numbing or detachment from others can also be signs of avoidance.
• Negative alterations in cognition and mood which includes persistent negative beliefs about oneself, others, or the world.
• Sufferers can experience distorted blame of self and others and an inability to experience positive emotions.
• Hyperarousal symptoms involve irritability or anger outbursts.
• Hypervigilance includes being constantly on edge and having an exaggerated startle response.
• Further symptoms are difficulty concentrating and trouble sleeping, linked to nightmares or flashbacks.

PTSD Risk Factors

• Pre-trauma factors include pre-existing mental health conditions (depression, anxiety) or a genetic predisposition to anxiety disorders.
• Childhood adversity is another factor.
• Peritrauma factors involve the severity and nature of the trauma (e.g., sexual assault, terrorist attack) and the person's thoughts during it, like being a hostage.
• Post-trauma factors impeding recovery include lack of social support, repeated exposure to trauma, trauma reminders, and maladaptive coping strategies.
• Maladaptive coping strategies include drinking, drug use, and avoidance.

PTSD Treatment and Medication Management

• First-line treatments are SSRIs (e.g., Zoloft, Paxil, Prozac).
• Prazosin or Minipress can be used for nightmares or flashbacks.
• Mood stabilizers or atypical antipsychotics can be used for agitation.

Medication Options

• Risperidone and Seroquel are atypical antipsychotics that are available.
• Mood stabilizers: Lamotrigine and Depakote.
• Benzodiazepines are short-term and are for panic attacks.
• Minipress (Prazosin) is a blood pressure medication affecting the alpha-1 adrenergic blocker.
• It is often used off-label for PTSD-related nightmares and can promote sleep.
• The mechanism involves alpha-adrenergic blockade, blocking alpha-1 receptors, leading to relaxation of blood vessels and reduced blood pressure.
• Minipress reduces the body's hyperarousal response to adrenaline.
• Propranolol lowers hyperarousal symptoms of anxiety but is not as effective as Minipress for PTSD.
• Minipress dosage usually starts at 0.5 and can be titrated up to between 1 and 15.
• For hypertension, the dosage is between 1 and 20.
• Side effects: dizziness, drowsiness, orthostatic hypotension, nausea, vomiting, and headache.
• Uncommon side effects: blurred vision, urinary incontinence, and impotence.
• Caution: Consider renal impairment, dialysis, or kidney issues.

Further Considerations for PTSD Treatment

• Avoid Minipress in older patients or those with hypertension and nightmares due to the risk of excessively lowering blood pressure.
• Minipress aims to improve the quality of life for those with intense nightmares and flashbacks and may not be for long-term use.
• Cognitive behavioral therapy, especially trauma-focused therapy, helps reframe negative thoughts related to the trauma.
• EMDR (eye desensitization and reprocessing) involves guided eye movements to process traumatic events and memories.
• Prolonged exposure therapy can reduce negative thoughts and avoidance behaviors.
• Exercise caution to avoid re-traumatizing the individual.

Acute Stress Disorder

• It is similar to PTSD but occurs within three days to one month after the trauma.
• If symptoms persist beyond one month, it may develop into PTSD.
• Common symptoms include dissociative symptoms, intrusive thoughts, flashbacks, nightmares, avoidance of trauma-related stimuli, and hyperarousal.
• Emotional numbing or amnesia may occur as a defense mechanism.
• Treatment includes short-term crisis intervention. Group therapy or counseling may be needed.
• Options also include trauma-focused CBT, SSRIs, or short-term benzodiazepines.

Adjustment Disorder

• This involves a maladaptive emotional or behavioral response to a stressful life event within three months.
• Stressors are less severe than PTSD, such as divorce or job loss.
• Symptoms include depression, anxiety, and anger. Children may exhibit conduct problems or have trouble sleeping.
• Treatment involves CBT, supportive therapy and counseling, and possibly short-term antidepressants.

Dissociative Disorders

• Dissociative disorders involve disruptions in memory, identity, emotions, perception of reality, and behavior.
• They are often linked to severe childhood trauma and abuse.
• Dissociative Amnesia causes an inability to recall important personal information, usually following trauma.
• Localized amnesia: Cannot recall events during a particular time period.
• Selective amnesia: Partial memory loss of an event.
• Generalized amnesia: Complete memory loss, this is uncommon
• Dissociative Fugue is a sudden travel or wandering away from home with identity confusion.
• Treatment includes trauma-focused therapy and cognitive techniques to improve memory recall.

Dissociative Identity Disorder (Multiple Personality Disorder)

• Requires the presence of two or more distinct personality states or alters.
• Each identity exhibits different memories, behaviors, and speech patterns, and sometimes has a foreign accent or immature voice.
• Often related to severe, repeated childhood abuse.
• Symptoms include memory gaps or time loss.
• Alters taking over can result in quick changes in mood, behavior, and identity.
• Increases in self-injurious behaviors and suicidal tendencies can also occur.
• Treatment: Long-term psychotherapy, aims to integrate all identities into one by making the patient aware of all personalities.
• CBT and DBT can be also used.

Depersonalization vs. Derealization

• Depersonalization is feeling detached from oneself.
• Derealization is an outer-body experience.