Post-Traumatic Stress Disorder (PTSD) PDF

[Post- Traumatic Stress Disorder] Relatively new disorder (**1980s**), often described as **shell shock** in WW2. The belief at the time was the **condition could only be found in war-related environments and that it was a symptom of war**. This suggests the **symptoms would disappear** once the en...

[Post- Traumatic Stress Disorder] Relatively new disorder (**1980s**), often described as **shell shock** in WW2. The belief at the time was the **condition could only be found in war-related environments and that it was a symptom of war**. This suggests the **symptoms would disappear** once the environment changes. PTSD is no longer known as an anxiety disorder but a **trauma and stress-related disorder.** A diagram of a stress disorder Description automatically generated Those with **Reactive attachment or disinhibited social engagement disorder** often experience traumatic stressors in **childhood** like prolonged **abuse or neglect**, or even if the child formed **no attachment** to a caregiver. Children **with reactive attachment disorder** may **shy** away from **interactions** and **avoid eye contact**. They may have **difficulty developing any attachments**. While **disinhibited social engagement disorder** consists of outgoing children that are **extremely social, impulsive and unable to distinguish** between appropriate **boundaries** of strangers. Adjustment disorders would be diagnosed in **adulthood**. It is developed through the **difficult adjusting to everyday life stressors**. **PTSD** and **Acute stress disorder** are concerned **with traumatic life-threatening events**. There should be an element of being **exposed to death or threat to your physical/mental/sexual integrity**. Those with **PTSD** are diagnosed after experiencing **symptoms for at least 1 month** but **Acute stress disorder** is diagnosed in people who have had symptoms for **less** than 1 month. These guidelines are put in place to account for spontaneous recovery.  The **DSM** stated that the experience must entail **direct (victim) or indirect (witness)** **exposure** **to real or imagined threats of death or injury/violence**, this includes **indirect exposure to aversive details of the trauma** (1^st^ responders). They must have **more than 1** of the following **intrusive symptoms**: unwanted **upsetting memories, nightmares, flashbacks, dissociative reactions,** intense/**prolonged psychological distress** at the exposure to **internal/external cues that symbolize/resemble the trauma**, marked **psychological reactions** to internal/external cues. There must also be **persistent avoidance of trauma** related **thoughts/feelings or external reminders**. The individual needs to experience **2 or more changes in mood/thought processes**: **inability to recall key features** of the trauma, **overly negative thoughts** about **oneself/world**, **exaggerating blame** of trauma to self or others, **negative** affect, **decreased interest**, feeling **isolated**, **difficulty** experiencing **positive** affect. Must experience **arousal and reactivity in the form of (2 or more**): **recklessness**, **aggression**, **hypervigilance**, **inability** to **concentrate**, **exaggerated** startle, **difficulty sleeping**. All symptoms must be present for **at least a month**. There are **2 dissociative subtypes**: **Depersonalisation** or **Derealisation**. Depersonalisation is a **discontinuity** in experience of self, **estranged from own mental processes or body**. Whereas Derealisation is **discontinuity** in the experience of the **environment** (unreal). highly comorbid with alcoholism especially with men  [Epidemiology:] **Kessler et al (2017**) stated **70**% of people experience a **lifetime trauma** that can qualify as a PTSD triggering event. However, the lifetime prevalence of PTSD is only **2.2- 8.8%** and **30% among veterans** (**repeated trauma = more prevalence**). The ratio of women to men is **2.4: 1**. the more direct the trauma, the more likely to develop (interpersonal element) childhood important Other **features of the trauma affect risk of development** such as **duration**, **frequency**, **perceived lethality**. [Complex PTSD (ICD-11):] This is a condition where **sufferers experience PTSD symptoms as well as emotional dysregulation** (marked irritability, anger, numbness), **negative self-cognition** and worth (self-view diminished/defeated, worthless) & **relationship difficulties (sustaining or closeness)**. Its suggested this is **linked to experiencing prolonged/repeated trauma, especially during developmental years**). However, some evidence suggests that it **can occur with** **adult** **traumas with high interpersonal intensity and severity of exposure**.  [Pathophysiology:] A diagram of a human body Description automatically generated The **stress response (Amygdala)** is **dysregulated**, causing **hyperactivity** in the area that presents as **acute life-threatening trauma**. This is concurrent with symptoms like **hypervigilance**. The stress response **never returns to the baseline** or downregulates. The **hippocampus** has **reduced activity/volume** in those with PTSD. The **hippocampus** is important for **contextualizing information** (**encoding** memory as a **past** event), so this finding has been linked to **intrusive memories** of sufferers. **HPA** **axis** is a system that **regulates stress responses**. It runs from the **hypothalamus**, which releases **CRH** to the **pituitary gland**. This gland releases **ACTH** onto the **adrenal** **gland**, which releases **adrenaline** (**short** term responses) or **cortisol** (**long** term). Those with PTSD have **lower cortisol levels**, this could be because cortisol may also **downregulate** responses, which does not occur in PTSD. Other researchers consider **lower cortisol levels to be a vulnerability** factor for developing PTSD. [Biological risk factors:] **Heritability** is around **30-40%**, these genes may be **characteristic** that make them more at **risk of exposure** to trauma (e.g. reckless) or **more reactive** to it. **Elevated** levels of **norepinephrine and dopamine** have been found to be associated with PTSD and the **learning of fear**. Its possible that those with elevated levels of these hormones may have **stronger associations with fear stimuli**. There is also a **reduction** in **cortisol** (HPA axis unregulated) and **serotonin**, this has been linked to **increased startle response** and fear memories. There are also studies focused on **Epigenetic** **changes**. This is the study of how **peoples' experiences change the expression of genes**. For example, **animal studies** found mice **learnt have an aversion to a smell**, their **offspring** were then born with this same **aversion**. This suggests the **learning event triggered activation/expression of** these genes which is then **passed on** to offspring. The **hippocampus**, **prefrontal cortex and anterior cingulate cortex** are **underactive**, this suggests the **limbic system fires excessively** as there is no downregulation (could explain hyperactive amygdala). This could be a **risk** factor or a **result** of the disorder. **Previous stress exposure is a major risk** for PTSD upon **re-exposure** to trauma (even if the trauma is different). For example, the **amygdala** is **hyperactive** in people with **child abuse**. The brain activity of soldiers was measured before and after service, it was found that those that developed PTSD showed **increased amygdala response for negative stimuli before service**. This suggests **amygdala hyperactivity may predispose** people to PTSD. [Environmental risk factors:]  **Traumatic loads** is the idea the **more you experience trauma, the more vulnerable** you are to PTSD. There are **pre-trauma factors like premorbid** (uncontrolled) **mental health problems**, **previous trauma** and **gender**. **2x more women** experience PTSD, however, findings are mixed. Research found **men are more inclined to confounding symptoms** (coping like substance abuse) which harder to **link casualty**. Other studies suggest **anxiety and subjective threat perception increase** in **women**. **Peri-trauma** (during) factors: trauma **type**, **frequency**, **duration**, **impact**, **perceived threat, dissociation** (more vulnerable), **severity**. **Post-trauma factors:** **social support, comorbidities** (**depression** confers higher risk), **dysfunctional cognitions (negative/repetitive)**. [Cognitive model of PTSD:] This suggests the way people **interpret** the event is important. A **catastrophic inference** of events **explains the ongoing sense of threat**. A study found a **24% variance** in whether fire fighters developed PTSD or not, this could be explained through their **different interpretations**. **Elhers & Clarke (2000)** developed a framework called **mental defeat**. It suggests those that **experience trauma often**, develop as view of themselves as **vulnerable victims**. They are **disempowered, lack resilience and coping abilities**. This mental framework is detrimental, **increasing the risk of both development and persistence** of the condition. [Conditioning theory:] **UC stimulus causes the UC fear response**. A **neutral stimulus** (similar to UC) becomes **conditioned with a fear response**. This could explains why those with PTSD have **numerous triggers (internal or external)**. **Avoidance** of the CS leads to the maintainment through **negative reinforcement** and **the lack of extinction** (no exposure). [Fear network:] A diagram of a person\'s health Description automatically generated Traumatic memories are **encoded with situation cues** and the **person's response** but also the individuals **interpretation of the experience**. This makes the traumatic memory **stronger** than other memories, if **any element of the memory is retrieved, the whole memory is recalled**. The **strong association** makes it **difficult to rewrite** as **every retrieval strengthens** the association. This also **explains the large number** of **triggers** for PTSD patients. [Dual representation theory: ] **Brewin** (2001) distinguished between **2 memory systems**: **Verbally accessible memory & situationally accessible memory**. VAM stores **consciously processed memories** in the **hippocampus**, they are ordered and **contextually** coded. SAM are **brief subconscious snapshots** in the **amygdala**, that are often recalled as **flashback** since they **can't be verbalized**. **Treatment** of PTSD would involve creating **narratives**, to **turn SAM to VAM**. [Treatment:] **65.3% of sufferers seek help** in their lifetime, with **7.1 %** seeking treatment within a **year of onset**. Wang et al (2005) states there is a **median duration delay of 12 years**. The **NICE guidelines** state the 1^st^ line of treatment should be **trauma-focused CBT or** **EMDR.**  The **CBT** focuses on **cognitive** **restructuring** and trying to **change** **dysfunctional behaviours or cognitions** that impede the elaboration of the trauma. A screenshot of a screen Description automatically generated**Exposure** for PTSD can take the form of **In Vivo** (in real life) or In Vitro/ **imaginary** or Interoceptive (confronting inner symptoms). It can either be gradual **systematic desensitization** or rapid **flooding**.  **EMDR** is the **movement of a finger** (side to side) in front of patients face. It is **unclear** what the underlying mechanisms are in this process but its suggested to **involve the working memory**. It's a **form of exposure**, where the patient is asked to **relive or talk about the past** while the **movement captures their attention**, possibly **engaging less with the emotional element** of the memory of the fear and are **better able to cope**. Some people suggest it is **connected to hemispheric synchronization**, where both hemispheres are recruited and working in **conjunction**. Some argue it mirrors **REM-like movement** for the eyes. It is **more** **effective than no treatment**, mostly due to the **exposure** element. It also provides **supportive listening and relaxation**. Some argue the **eye movements** are the essential component.