WEEK 8/9 - Trauma and Stress Related

tsrd distinguishing feature

the stressor is the cause of distress, while with anxiety disorders the perception or interpretation of an event causes distress

ptsd history

historically considered an anxiety disorder, but has dissociative elements not found in anxiety syndrome categories

tsrd disorders

posttraumatic stress disorder (ptsd), acute stress disorder, adjustment disorders, reactive attachment disorder, disinhibited social engagement disorder, other specified trauma and stressor-related disorder, unspecified trauma and stressor-related disorder

shell shock

world war I modern psychiatric judgement: sudden muteness, deafness, tremors, catatonia, brief loss of consciousness. psychiatric patients were the most common in WWI armed forces

secondary gain

world war I modern psychiatric judgement:: increase of traumatized war veterans on streets. considered this disorder as it curried lucrative sympathy (honourable discharge + benefits)

cowardice

world war I modern psychiatric judgement: soldiers were executed for this disorder by military orders for presenting with symptoms of gross stress reaction, now referred to as acute stress disorder

residual diathesis source

immediate and enduring stress following a traumatic event (lasting injury)

ecological diathesis source

pre- and post-trauma factors related to social support and interpersonal relationships (absence of support)

biological diathesis source

neurocognitive diatheses developed during childhood that predisposes trauma survivors to hyperarousal and dissociation

diathesis-stress

psychological disorder is thought to be the result of an interaction between an external stressor, the stress response, and the internal vulnerability

the degree of vulnerability can be somewhat quantified by a range of factors (biological, physical, neurological, psychological, or sociological)

stress

the result of a real or perceived mismatch between an environmental demand and the individual’s ability to cope (both real and perceived)

• failure to meet demand has consequences to well-being, larger gap between environment demand and coping capacity, greater strain on individual’s resources, creating greater experience of this term

eustress

when the strain of the environmental demand is within an individual’s coping capacities and facilitates adaptive responding

distress

when the strain of environmental demand is outside an individual’s coping capacities and disrupts adaptive responding

type 1 trauma

defined as a “singular shock” (a simple event) from which one can recover

type 2 trauma

refers to repeated episodes of shocks

type 2r trauma

is when the sufferer experiences repeated psychological shocks, but has enough emotional resources (both personally, and within social circle) to cope

type 2nr trauma

refers to the experience of repeated shocks, with little to no resources to cope and recover, resulting in the compounding of traumatic experiences and subsequent vulnerability to further post-traumatic reactions

acute stress disorder criterions

(a) exposure to actual or threatened death, serious injury or sexual violation in one or more of the following ways:

• (b) presence of 9 or more symptoms from 5 categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after traumatic events occur

• (c) the duration is 3-30 days

• (d) disturbance causes clinically significant distress or impairment

• (e) the disturbance is not attributable to anything else

acute stress disorder context

ptsd not diagnosed until 30 days post-trauma, but trauma survivors still display reactions, therefore a minimum duration of 30 days was added to pstd criteria and this disorder was created to fill the gap

acute stress disorder conceptual issues

• acute stress disorder and dissociation are unreliable predictors of ptsd. acute stress disorder represents a severe stress response but does not capture trauma reaction heterogeneity (Bryant et al., 2011)

• 43 female assault survivors, 100% met criteria for ptsd when duration was ignored, only 58% met acute stress disorder criteria

adjustment disorder (ad) criteria

• (a) the development of symptoms in response to identifiable stressors occurring within 3 months

• (b) distress out of proportion to the stressor (after considering sociocultural/ethnic context, life status) socio-occupational impairment

• (c ) the disturbance is not an exacerbation of a pre-existing pathology and is not better explained by another disorder

• (d) the symptoms do not represent normal bereavement

• (e) once the stressor or its consequences have terminated, symptoms do not persist beyond 6 months

differential diagnosis ptsd

has dissociated subtype. includes symptoms in addition to the stress response such as avoidance, safety behaviours, depressive thinking and affect, and shattered core beliefs. required criteria A to be diagnosed

differential diagnosis asd

characterized by immediate stress response with dissociative elements unlike ptsd, and can only be diagnosed between 3 days and one month post trauma

differential diagnosis ad

can be diagnosed immediately and up to 6 months post-trauma, does not require criteria A to be met for diagnosis unlike asd and pstd

complex post-traumatic stress disorder (cptsd) criteria

meets all ptsd criteria which include: reexperiencing the trauma in the present, avoidance of trauma reminders, persistent sense of threat (hypervigilance). symptoms persist for months or years, follows prolonged or repeated interpersonal trauma, causes significant impairment, not better explained by personality disorder or other conditions (WHO, 2018)

• must include all three disturbances in self-organization (affective dysregulation, negative self-concept, interpersonal difficulties)

affective dysregulation

a disturbance in self-organization for cptsd criteria: difficulty managing emotions. either heightened emotional reactivity or emotional numbing/shutdown

negative self-concept

a disturbance in self-organization for cptsd criteria: persistent beliefs of worthlessness, failure or shame. Deep, stable sense of being damaged or diminished

interpersonal difficulties

a disturbance in self-organization for cptsd criteria: problems suistaining relationships. feeling distant, mistrustful, or unable to feel close to others

cpstd conceptual issues

borderline personality disorder (bpd) vc cptsd

• bpd showcases “frantic attempts to avoid abandonment, unstable self, unstable and intense interpersonal relationships, and impulsivity (Cloitre et al., 2014)

• cptsd characterized by unstable sense of self, but borderline personality disorder more so by temper outbursts (Jowett et al., 2020)

• cptsd predicted by cumulative childhood maltreatment and trauma exposure, shared by bpd but cptsd can occur in the absence of bpd (Frost, 2020)

• cptsd is distinguished by chronically negative self-concept, bpd is distinguished by alternating self-concept (Frost, 2020)

• bpd eternalizes anger, cptsd internalizing anger (Powers, 2022)

tsrd summary

AD - a stress response to a non-criteria A event

ASD - an acute and rapid stress response to a criterion A event characterized by dissociative experiences

PTSD - a disorder of traumatic reexperiencing, hyperarousal, and avoidance appearing soon after a criterion A event

C-PTSD - a disorder commonly experienced after chronic and repeated severe trauma that causes PTSD and subsequent lasting personality changes

ptsd risk factors for civilians

childhood trauma, additional life stress, social support, peri-traumatic dissociation, post-trauma social support, bpd, mdd, anxiety disorders

• prior trauma more predictive than current trauma exposure

• pre-trauma variables confer vulnerability

ptsd delayed specification

a specifier of ptsd course: full diagnostic criteria are not met until at least 6 months after the trauma, although onset symptoms may occur immediately

derealization

a specifier of ptsd course: experience of unreality, distance or distortion (things that are not real)

ptsd depersonalization

a specifier of ptsd course: experience of being an outside observer or detached from oneself

intrusion symptoms of criteria B

• recurrent, involuntary and intrusive distressing memories of the traumatic event

• recurrent distressing dreams related to distressing event

• dissociative reactions in which individal feels or acts as if traumatic events were recurring

• intense or prolonged psychological distress at exposure to internal/external cues symbolizing traumatic event

• marked physiological reactions to internal/external cues that symbolize traumatic event

avoidance of stimuli symptoms of criteria c

• avoidance of or efforts of avoiding distressing memories, thoughts, or feelings closely tied to traumatic event

• avoidance or efforts to avoid reminders that arouse distressing memories closely associated with traumatic events

negative alterations in cognition or mood criteria d

• inability to remember important aspect of traumatic event, not related to a head injury, alcohol or drugs

• persistent and exaggerated negative beliefs or expectations about oneself

• persistent distorted cognitions about the cause or consequences of traumatic event that lead individual to self-blame

• diminished interest in participation in significant activities

• feelings of detachment or estrangement from others

• persistent inability to experience positive emotions

alterations in arousal and reactivity criteria e

• irritable behaviour and angry outbursts with little to no provocation, expressed as verbal or physical aggression towards people/objects

• reckless or self-destructive behaviour

• hypervigilance

• exaggerated startle response

• problems with concentration

• sleep disturbances

eye movement desensitation and reprocessing

innovative evidence-based psychotherapy for ptsd that uses bilateral stimulation (eye movements) to facilitate the activation and processing of traumatic memories. effective but adds nothing to intervention (Davidson et al., 2011)

• classical conditioning + extinction trial = desensitization

• orienting response + eye movement = relaxation

• adaptive response to stimuli leads to hyperarousal, then relaxation if no danger is present

emdr working memory hypothesis

eye movements and visual imagery combined tax the visuospatial sketchpad and central executive functioning, reducing disturbing images and thus emotion. degredation of fear response from images creates distance from traumatic event (Englehard et al., 2011)

ptsd genetic aetiology

• pstd is polygenic: not caused by a single gene

• studies estimate 30% of ptsd risk is heritable

• gene x environment interactions are central. genotype increases risk only when combined with childhood adversity

• ptsd associated with altered DNA methylation patterns, including glucocorticoid receptor gene promoter changes

ptsd fear conditioning and extinction

• ptsd reflects over-consolidation of fear memories and failure of extinction

  • amygdala central nucli encodes threat associations

  • medial prefrontal cortex, inhibits amygdala but is impaired in ptsd

  • hippocampus contextual memory and impaired contextualization creates overgeneralized fear. implicates problems extinguishing fear

  • monoamines like norepinephrine and dopamine modulate fear learning and memory consolidation

ptsd threat detection and emotion regulation

hyperreactivity related to amygdala, insula, dorsal salience network

hyporeactivity: related to medial and lateral prefrontal cortex

• results in heightened threat detection, top-reduced control, persistent hypervigilance

ptsd stress response theory

Intrusive re-experiencing of flashbacks cause avoidance and emotional numbing, which reintroduces the intrusive flashbacks (Horowitz, 1986)

• Homeostasis: processing flashbacks, then avoidance

• Frequency and severity of flashbacks decrease overtime (completion tendency). if it does not stop, ptsd is the result

• this cycle is responsible for ptsd symptoms and continues indefinitely

ptsd shattered assumptions theory

coined by Janoff-Bulman, 1986

• humans build early assumptions based on experience, particularly about safety

• part of schemas, an unconscious psychological model for relating to oneself, others and the world

• to maintain stability, we process experience so it is biased towards maintaining schemas. schemas may change with slow and steady integration of new experiences, resulting in synthesis from old to new experiences into modified schema

• traumatic experiences shatter assumptions, resulting in a struggle to integrate events where schemas about safety were violated, overwhelming processing ability

dual representation theory

coined by Brewin et al in 2010, theorizes that ptsd occurs whne the processing responsible for integrating contextual memory and situation-based memory has been impaired by the trauma + diathesis interaction (Wakefield’s harmful dysfunction)

contextual memory

contains memories processed at the time of the trauma. its contents are confined to the attention window/span. they are abstract, verbally accessible and viewpoint independent (Brewin et al., 2010)

• supports integration of knowledge and abstract simulation of scenarios and ideas

situation-based memory

comprises sensory perceptions, physiological and immediate emotional reactions that were processed unconsciously. they are concrete, situationally-accessible and viewpoint dependent. (Brewin et al., 2010)

• automatically and involuntarily triggered by trauma cues. can be hard to communicate verbally. support immediate autonomic response and action

situational memory representations

a part of Brewin et al’s 2010 dual representation theory and criteria B for ptsd: represented by involuntary flashbacks. contain perceptions of the traumatic scene such as physical sensations of anxiety and basic emotions

• triggered by trauma cues and not retrieved virbally and dissociated from long-term memory with zero context

• flashbacks are experienced as “happening now” without context, making them traumatic, confusing and alarming

contextual memory representation

a part of Brewin et al’s 2010 dual representation theory and criteria C for ptsd: complex and contain complex emotions like helplessness and horror. serve as the communicable aspects of traumatic event, and make up the individual’s cognitive evaluations of their truama, and its perceived effect on themself and their world

recovery

a cognitive process of Brewin et al’s 2010 dual representation theory: occurs because contextual memory representation is easily accessible, and in turn is marked by symptom reduction

Chronicity

a cognitive process of Brewin et al’s 2010 dual representation theory: occurs when situational memory representation is received with no ensuing symptom reducing, marking a lack of patient recovery

• may occur when trauma interacts with prior negative schema, creating a competing demand for coping resources/social support

premature inhibition

a cognitive process of Brewin et al’s 2010 dual representation theory: occurs when trauma survivors develop avoidance strategies to suppress symptoms

• short term reduction of symptoms, but creates memory impairments, hypervigilance and a long-term risk increase of re-traumatization heightening ptsd symptoms

emotional processing model

a model of treatment by Foa & Kozak in 1986:

• the experience of fear is represented in associative networks within the brain called “fear structures” containing representations of conditioned stimuli, andcognitive/emotional/physiological/behavioural reactions and are activated to deal with danger

• fear structures that accurately depict simuli are adaptive and effective, but inaccurate fear structures are not and generate pstd

• inserting corrective information into fear structures via exposure will stabilize it, reducing activation and thus pstd symptoms

• part of Prolonged Exposure Therapy (Foa Rothbaum, 1988)

ptsd cognitive model

a treatment model by Ehlers & Clark, 2000: those who have experienced a traumatic event tend to then exhibit symptoms from ptsd: in most cases, these memories are gradually processed, and re-experiencing/hyperarousal decreases over short period of time

• theory suggests those who experience ptsd symptoms indefinitely process memories in a way that leads them to experience a sense of current threat

• current threat is caused by unhelpful negative appraisals of trauma experience and ensuing symptoms, trouble sufficiently elaborating on and integrating memories into autobiographical long-term memory with context

  • this is because memories are triggered by broad stimuli and generate intense emotions, contributing to current threat as a perpetuation of ptsd

ptsd key features of cognitive model

Ehlers & Clark (2000) theorize the role of “mental defeat",” a peri-traumatic cognitive event in which the individual identifies strongly as a victim is biased towards processing trauma information, heightening distress and maladaptive coping

• diminishes with trauma exposure dose and re-exposure (Wilker et al., 2017)

• a prediction of symptom severity, alongside confusion and detachment: leads to poor therapy outcomes without cognitive restructuring (Ehlers et al., 1998)

ptsd pharmacotherapy

• new generation SSRI’s first-line drug treatment for ptsd. (Brady et al., 2000)

• reversible inhibitors of oxidase (RIMAs) replaces MAOIs due to lacking side effects

• Benzodiazepine widely used but no better than placebo

• Fluoxetine emerged as optimal drug on balance of effectiveness and side-effects