DSA31 - PTSD, Trauma, and Violence (CPS/APS)

Posttraumatic Stress Disorder

Define Condition:

> DIAGNOSTIC CRITERIA:

>> A = Exposure to Trauma

>> B = Intrusion

>> C = Avoidance

>> D = Negative Cogs/Mood

>> E = Hyperarousal

>> F = Persistence of Sx in B, C, D & E for > 1 month

>> G = Sx related distress or functional impairment

>> H = NOT d/t meds, substance, or illness

-Hx:

> Risk Factors:

>> Younger Age

>> FEMALE

>> Unmarried

>> Less Education

>> Lower SES

>> Unemployed

> Common Causes (Traumas):

>> Vehicle Accidents

>> IPV/DV/Sexual Assault

>> Child Abuse/Elder Abuse

>> Life-threatening illness, particularly ICU hospitalization

>> Pregnancy loss/emergency

>> Combat trauma

>> Natural Disasters

>> Refugee experiences

>> Mass Casualty Events

-Path:

> Heightened amygdala response

> Decreased medial PFC response (inhibit amygdala)

> Smaller anterior cingulate cortex/hippocampal volumes (excessive cortisol from stress response)

> Hyperactive locus coeruleus (increased NE release)

-Sx/PE: May have Depersonalization and/or Derealization Sx

-Dx:

> Screening:

>> PTSD Checklist-5 (PCL-5)

>> Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)

>> Child PTSD Symptom Scale (CPSS) – Children/Adolescents

>> Young Child PTSD Screen – Children under age 6

The person was exposed to: DEATH, THREAT OF DEATH, ACTUAL/THREAT OF SERIOUS INJURY, or ACTUAL/THREAT SEXUAL VIOLENCE, as follows:

-DIRECT EXPOSURE to traumatic event(s)

-WITNESSING, in person the event(s) as it occurred to others

-Indirectly, by LEARNING that a close RELATIVE/CLOSE FRIEND WAS EXPOSED to trauma (If the event(s) involved actual or threatened death, it must have been violent or accidental)

-REPEATED or EXTREME INDIRECT EXPOSURE to aversive details of the event(s), usually in the course of PROFESSIONAL duties (e.g., first responders, collecting human remains; professionals repeatedly exposed to details of child abuse).

[Does not include indirect non-professional exposure through electronic media, television, movies or pictures]

Explain PTSD Criteria A (Exposure to Trauma)

1/5 NEEDED - a/w event(s), began after:

-RECURRENT, INVOLUNTARY & INTRUSIVE RECOLLECTIONS ( children may express this symptom in REPETITIVE PLAY OF TRAUMA)

-TRAUMATIC NIGHTMARES

-DISSOCIATIVE RXNS (e.g. flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness

-Intense or prolonged DISTRESS AFTER EXPOSURE to traumatic REMINDERS

-Marked PHYSIOLOGICAL RXN after exposure to trauma-related STIMULI

Explain PTSD Criteria B (Intrusion)

1/2 SX NEEDED = Persistent effortful avoidance of distressing trauma-related stimuli after the event:

-Avoid Trauma-Assoc THOUGHTS/MEMS/FEELINGS

-Avoid Trauma-Assoc REMINDERS (People, Places, Conversations, Activities, Objects, Situations)

Explain PTSD Criteria C (Avoidance)

2/7 SX NEEDED = Began or worsened after the traumatic event:

-INABILITY TO RECALL important ASPECTS of the TRAUMATIC event(s) (usually 2/2 dissociative amnesia; not due to head injury, alcohol or drugs)

-PERSISTENT AND EXAGGERATED NEGATIVE BELIEFS and EXPECTATIONS about oneself, other, or the world (e.g. "I am bad," "the world is completely dangerous", "no one can be trusted" "My whole nervous system is permanently ruined")

-PERSISTENT DISTORTED COGNITIONS about the CAUSE or CONSEQUENCES of the traumatic event(s) --> BLAME SELF/OTHERS

-PERSISTENT NEG EMOTIONS (e.g. fear, horror, anger, guilt, or shame)

-Markedly DIMINISHED INTEREST OR PARTICIPATION in significant activities

-Feeling DETACHED/ESTRANGED from others

-Persistent INABILITY TO EXPERIENCE POSITIVE EMOTIONS

Explain PTSD Criteria D (Neg Cogs/Mood)

2/6 SX NEEDED - Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event(s):

-IRRITABLE or AGGRESIVE behavior (with little to no provocation)

-SELF-DESTRUCTIVE or reckless behavior

-HYPERVIGILANCE

-EXAG STARTLE response

-CONC ISSUES

-SLEEP DISTURB

Explain PTSD Criteria E (Hyperarousal)

< 3 mo

According to PTSD Criteria F, what is the amount of time for B-E Sx to occur for PTSD to be considered ACUTE?

> 3 mo

According to PTSD Criteria F, what is the amount of time for B-E Sx to occur for PTSD to be considered CHRONIC?

Sx onset occurs > 6 mo after traumatic event

According to PTSD Criteria F, what is the amount of time for B-E Sx to occur for PTSD to be considered Delayed Onset?

> Trauma criteria is unchanged MINUS LACK OF OCCUPATIONAL EXPOSURE

> INTRUSION CHANGES:

>> Traumatic nightmares = children may have DISTURBING NIGHTMARES W/O TRAUMA-RELATED CONTENT

>> Dissociative reactions (e.g. flashbacks) - children may RE-ENACT IN PLAY

> Need ONLY 1 SX from AVOIDANCE or NEG COGS/MOOD (Does NOT include symptoms = poor recall; foreshortened view of future; persistent blame of self or others)

> RECKLESS behavior EXCLUDED FROM HYPERAROUSAL

What are the key differences in Dxing PTSD in children under 6 y/o?

When child can EXPLORE FREELY while the caregiver is present --> typically engages with strangers, upset when the caregiver departs, happy to see the caregiver return

Define Secure Attachment

Child EXPLORES LITTLE and is often wary of strangers, even when the caregiver is present --> When the caregiver departs, the child is highly distressed BUT the child is generally ambivalent when the caregiver returns

Define Anxious-Ambivalent Attachment

Child will NOT EXPLORE very much REGARDLESS OF WHO IS THERE --> Avoid or ignore the caregiver and showing little emotion when the caregiver departs or returns.

Define Anxious-Avoidant Attachment

Child shows mixed response to presence, departure, and return of caregiver

Define Disorganized/Disoriented Attachment

Acute Stress Disorder

Define Condition:

Criteria A = EXPOSURE To Trauma (Same as PTSD)

Criteria B = 9 or more symptoms

> Intrusions symptoms of (1) memories (2) nightmares, (3) flashbacks, with (4) marked psychological or physiological distress

> (5) Inability to experience positive emotions

> (6) Derealization or Depersonalization

> (7) Poor recall of an important aspect of the event(s)

> (8) Avoidance of memories/thoughts/feelings

> (9) Avoiding reminders of trauma

> (10-14) Hyperarousal symptoms minus reckless behavior

Criteria C = Duration of symptoms is between 3 days to 1 month after exposure

Criteria D = Significant symptom-related distress or functional impairment

Criteria E = R/O cause of medication, substance or illness, OR not better explained by Brief Psychotic D/o

Reactive Attachment Disorder

Define Condition:

Criteria A = Consistent pattern of inhibited emotionally withdrawn behavior toward adult caregivers manifest by both of the following:

1. The child rarely or minimally seeks comfort when distressed

2. The child rarely or minimally responds to comfort when distressed

Criteria B = Persistent social and emotional disturbance characterized by at least 2 of the following:

1. Minimal social and emotional responsiveness to others

2. Limited positive affect

3. Episodes of unexplained irritability, sadness, or fear that are evident even in interaction with nonthreatening adults

Criteria C = The child has experienced a pattern of extremes of insufficient care as evident by 1 of the following:

1. Social neglect or deprivation

2. Repeated changes of primary caregivers that limit opportunity to form stable attachment

3. Rearing in unusual settings that limit opportunity to form stable attachment

Criteria D = Criterion C is presumed to be responsible for the disturbed behavior in Criterion A

Criteria E = R/O ASD

Criteria F = Disturbance is evident before age 5

Criteria G = Child has a developmental age of at least 9 months

Disinhibited Social Engagement Disorder

Define Condition:

Criteria A = Consistent pattern behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following:

1. Reduced or absent reticence in approaching and interacting with unfamiliar adults

2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries)

3. Diminished or absent checking back with caregivers after venturing away, even in unfamiliar settings

4. Willingness to go off with an unfamiliar adult with minimal or no hesitation

Criteria B = That Criterion A is not limited to impulsivity (as in ADHD) but include socially disinhibited behavior

Criteria C = The child has experienced a pattern of extremes of insufficient care as evident by 1 of the following:

1. Social neglect or deprivation

2. Repeated changes of primary caregivers that limit opportunity to form stable attachment

3. Rearing in unusual settings that limit opportunity to form stable attachment

Criteria D = Criterion C is presumed to be responsible for the disturbed behavior in Criterion A

Criteria E = = Child has a developmental age of at least 9 months

Adjustment Disorder

Define Condition:

The development of emotional or behavioral symptoms in response to a stressor(s) occurring within 3 months of the onset of the stressor(s)

-S/S:

> Sx:

>> Depressed mood – low mood, tearfulness, hopelessness

>> Anxiety – nervousness, worry, jitteriness, separation anxiety

>> Mixed Anxiety and depressed mood

>> Disturbance of conduct

>> Mixed disturbance of emotions and conduct

Symptoms or behaviors cause 1 or both of the following:

> Marked distress that is out of proportion to the severity or intensity of the stressor (not normal bereavement) taking into account the external context and the cultural factor that might influence symptom severity or presentation

> Significant functional impairment

-Prog = Shouldn't last for more than an additional 6 months

CBT with trauma focus

What does Tx involving EARLY PREVENTION look like for PTSD & Related D/o?

-Prolonged Exposure Therapy

-Flooding

-Systematic desensitization

-Narrative exposure therapy

What are some Psychological Options for Tx of PTSD & Related D/o?

Structured therapy that reduces the vividness and emotion of trauma memories by using bilateral stimulation

Define Eye Movement Desensitization and Reprocessing (EMDR)

> FDA Approved - Sertraline, Paroxetine

> Off-label: Fluoxetine and Venlafaxine also recommended

What are first line Antidepressants that can be used for PTSD Tx?

> Prazosin - for trauma related nightmares

> Other SSRI/SNRI

> Beta-blockers

> Anticonvulsants - mixed results, some benefit with topiramate in veterans

> Antipsychotics - inconsistent evidence

> Risperidone and quetiapine for veterans

> Olanzapine for civilians

What are off-label Pharm Tx for PTSD?

> Cannabinoids (reduce amygdala activation, block trauma recall)

> MDMA-assisted psychotherapy (reduce anxiety response during trauma recall)

What are some newer Tx for PTSD?