Trauma/Stress Related Disorder

what is post-traumatic stress disorder?

Exposure to threatened or actual death, violence, or serious injury with at least one intrusive symptom associated with traumatic event with duration of > 1 month with clinically significant distress or impairment.

How can someone be exposed to a traumatic event?

via directly experiencing it, witnessing an event that happened to others, discovering a traumatic event occurred to a close family member or friend (and if there was actual or threatened death, was violent or accidental), experiencing extreme or repeated exposure to unpleasant details of traumatic event

Examples of intrusive symptoms occurring after the traumatic event occurred:

involuntary/recurrent/and distressing memories, distressing/recurrent dreams with content related to event, dissociative reactions (flashbacks) where patient feels or acts as if the traumatic event was occurring, prolonged or intense psychological distress at exposure cues that resemble or symbolize the event

how does PTSD present?

avoidance of stimuli associated with the event (not previously avoided), negative alterations in mood or cognition associated with the event that began or worsened afterwards (>/= 2 ), changes in reactivity and arousal, depersonalization, derealization

describe avoidance of stimuli associated with event:

patient avoids/makes effort to avoid distressing thoughts, memories, or feelings about the event, and external reminds (i.e. places) that bring on distressing thoughts, memories, or feelings about the event.

what are the negative alterations in mood/cognition (>/= 2 for PTSD)

Inability to recall important pieces of the event

Exaggerated and ongoing negative expectations or beliefs about oneself, others, or the world

Continuous, distorted cognitions about the cause or consequences of the event causing individual to blame oneself or others

Continuous negative emotional state (horror, anger, shame)

Reduced interest or participation in important activities

Feels of being estranged/detached from others

Sustained inability to experience positive emotions

Examples of changes in reactivity and arousal (>/=2 for PTSD)

unprovoked irritable behavior and angry outbursts (verbal or physical aggression), self-destructive or reckless behavior, hypervigilance, excessive startle response, difficulty concentrating, sleep difficulty

what is depersonalization?

feeling detached, out of body or mind experience, slowed time

what is derealization?

unreality of surroundings (dreamlike, distorted, or distant)

If negative symptoms from traumatic events last 3 days - 1 month, what is it called?

Acute Stress Disorder

What is the severity of PTSD diagnosis determined by?

Pre-traumatic events, peri-traumatic events, and post-traumatic events

Examples of pre-traumatic events that play a role in PTSD severity diagnosis

prior psych diagnosis (family hx of psych diagnoses), hx of SUD or alcohol use, female > male, lower socioeconomic and educational level, maltreatment as child, maltreatment as child, previous trauma

Examples of peri-traumatic events that play a role in PTSD severity diagnosis

severity of trauma, perceived threat to life, emotional response, dissociation

Examples of post-traumatic events that play a role in PTSD severity diagnosis

perceived lack of social support, dysfunctional patterns of social interaction, subsequent life stress

Why would cortisol levels be lower than normal?

chronic adrenal exhaustion from persistent severe anxiety

what does a1-a2-adrenergic post synaptic receptor over stimulation lead to?

a1 receptors: startle/sleep response, disruption of REM sleep —> nightmares

what occurs when the sympathetic nervous system is dysregulated?

uncontrolled catecholamine release which causes memory formation disruption and exacerbated symptoms with cues

what are the first-line treatments for PTSD?

trauma focused psychotherapy or SSRIs (fluoxetine, paroxetine, sertraline) or SNRIs (venlafaxine)

what should be done if the antidepressant fails after 12 weeks at maximum dose?

switch to a different one

What should be done if a second trial of antidepressants fail?

Could try: TCA (imipramine, amitriptyline), mirtazapine, phenelzine, or nefazodone

which medications should be avoided in PTSD?

benzodiazepines

why should benzos be avoided in PTSD?

may worsen fear response and recovery 

how long should treatment last for PTSD?

12 months of treatment is recommended — many patients will NOT have a full resolution.

T/F: 40% of patients with PTSD have psychosis

true

how is psychosis in PTSD treated?

first treat with SSRI

Facts regarding SGAs in PTSD

They are preferred for psychosis but not as monotherapy treatment for PTSD (olanzapine, risperidone, quetiapine)

which medications may worsen insomnia/nightmares common with PTSD?

SSRIs

what is prazosin’s role in sleep?

Is not FDA approved but the adrenergic blockade modifies memory consolidation and disrupts fear process - reduced nightmare severity

what is the dosing for prazosin to treat nightmares/insomnia?

1-2 mg/day up to 13 mg QHS

facts regarding clonidine use in insomnia/nightmares

not FDA approved but some efficacy is noted

which medications are not FDA approved, cannot be used as monotherapy, and have some efficacy for insomnia/nightmares?

Cyproheptadine, trazodone, nefazodone, mirtazapine, olanzapine, quetiapine, TCAs, eszopiclone, and zolpidem

How do autism spectrum disorders present?

Social and emotional difficulties with interacting and communicating.

Poor comprehension/use of mannerisms or affect

Repeated, rhythmic, pattern of verbal/non-verbal actions, inability to deviate from standard schedule, limited and atypical fascination of specific interests, inappropriate rxn to stimuli.

Not explained by an intellectual disability (but can be accompanying)

Behavioral symptoms (aggression, hyperactivity, inattention, irritability, low frustration threshold, self-harm, severe temper tantrums, sleep disturbances, OCD-like symptoms, hypersensitivity of the senses

T/F: disruption from autism spectrum disorders need to be in early childhood (impact in academics, work-related, communication, or other areas of functioning) 

true

What are the autism spectrum disorder treatments?

Minimize core symptoms and problem behaviors; maximize independent functioning

Pharmacotherapy reserved for when ADLs, education, family life, and/or self-injury occurs; start low/go slow; treatments target comorbidity not ASD as a whole

when should treatment efficacy for ASD be evaluated?

after 3-4 weeks and re-evaluate if no response by 6 weeks

when should you reduce/discontinue ASD treatment?

After 6-12 months of therapy

which medications are FDA approved for disruptive behaviors in ASD?

aripiprazole (6-17 years old) and risperidone (5-17 years old)

Which disruptive behaviors do aripiprazole and risperidone help treat in ASD?

irritability, stereotyped and repetitive behaviors, self-injury, hyperactivity

which medications are NOT FDA APPROVED but are used for disruptive behaviors?

FGA (haloperidol, chlorpromazine, fluphenazine)

Alpha-2 agonists

Mood stabilizers

Glutamatergic agents (N-acetylcysteine, amantadine, memantine)

what is haloperidol’s role in ASD treatment?

0.25 - 4 mg/day can reduce social isolation and anger related behaviors

T/F: chlorpromazine and fluphenazine have limited data on treating ASD disruptive behaviors

true

explain the role of alpha-2 agonists in ASD disruptive behaviors:

some evidence shows decreased irritability

which mood stabilizer has modest effects on aggression in ASD?

Divalproex

what is the role of glutaminergic agents in ASD disruptive behaviors?

improvement in irritability with risperidone

T/F: there are no FDA approved options to treat repetitive behaviors seen in ASD

true

which medications are used off-label to treat repetitive behaviors in ASD?

SSRIs, antipsychotics, and divalproex

which antipsychotics can be used off-label for repetitive ASD behaviors?

risperidone, aripiprazole, and haloperidol

Why are SSRIs used in repetitive behaviors seen in ASD?

they may be effective for reducing OCD/anxiety since 5HT activation can cause increased activity, agitation, and insomnia

why are certain antipsychotics used off-label for repetitive ASD behaviors?

show significant reductions of repetitive behaviors

T/F: divalproex showed modest improvement vs placebo for repetitive ASD behaviors

true

T/F: melatonin is FDA approved for sleep in ASD

false

benefits of melatonin for sleep in ASD:

reduces sleep latency and increases length of sleep

how are ADHD symptoms from ASD treated?

MPH, AMP, Atomoxetine, aripiprazole/risperidone, alpha-2 adrenergic agonists

which stimulant is preferred for ADHD symptoms in ASD?

MPH > AMP

Facts regarding stimulant use in ASD treatment:

lower doses than ADHD are used and there is a higher risk of adverse effects such as irritability, social withdrawal, and emotional lability

Which ADHD symptoms respond better to stimulants in ASD?

hyperactivity (responds better than inattention with possible reduction in aggression)

role of atomoxetine in ADHD symptoms in ASD:

good for hyperactive and impulsive behavior, but does not improve global functioning

role of aripiprazole/risperidone in ADHD symptoms in ASD:

decrease hyperactive symptoms

role of alpha-2 adrenergic agonists in ADHD symptoms in ASD

modest effects on irritability, hyperarousal, and socialization 

what are tics?

repeated, non-rhythmic muscle movements or vocal utterances that occur suddenly, involuntarily, and meaninglessly

what is a tic disorder?

symptoms present almost every day starting prior to 18 years and lasting for at least one year

what is Tourette’s?

presence of at least two types of tics involving movement and one vocalization

which comorbid psychiatric, behavioral, or developmental disorders commonly co-occur with tic disorder/Tourette’s?

ADHD, conduct disorders, anxiety disorders (OCD)

what needs to be done for Tics/Tourette’s before starting medications?

8-10 weeks of non-pharmacologic therapy

T/F: alpha-2 agonists are FDA approved for tics/Tourette’s

false

which alpha-2 agonists are used in tics/tourette’s?

clonidine 0.05 mg/day titrated to 0.4 mg/day in divided doses

guanfacine 0.5 mg/day titrated to 4 mg/day

which SGA is FDA approved for pts 6-18 years old for Tourette’s?

Aripiprazole

which SGA are not FDA approved for tics/tourettes but are used?

risperidone, ziprasidone, quetiapine

Which FGA is FDA approved for those > 3 years for tics and vocal utterances?

Haloperidol

which FGA is FDA approved for pts > 12 years for severe motor and phonic tics?

Pimozide

ADRs/Precautions for using Pimozide:

Need ECG monitoring and has CYP1A2/2D6/3A4 interactions

which FGA is not FDA approved for tics/tourette’s but is used?

fluphenazine

what is oppositional defiant disorder?

Angers easily, envious, mad, quickly irritated, altercations with persons in command, refuses to follow instructions/rules, irritates others, blames others for their own behavior, vengeful or malicious. Family/peers are disturbed by the actions.

define oppositional defiant disorder for patients < 5 years old

symptoms daily for 6 months

define oppositional defiant disorder for patients > 5 years old

symptoms at least once a week for 6 months

what is conduct disorder?

Continuous repetitious pattern of behavior over the past 12 months - verbal/physician aggression to others, intimidating and threatening behaviors, use of an instrument that may cause physical harm, physical abuse to other humans or animals, forcible sexual activity, property destruction (arson), lying, stealing, deliberate disregard for laws and regulations

T/F: conduct disorder is more severe aggression compared to oppositional defiant disorder

true

T/F: Oppositional defiant disorder can turn into conduct disorder

true

How are oppositional defiant disorder and conduct disorder treated?

non-pharmacologic!

Antipsychotics, mood stabilizers, stimulants, atomoxetine

which antipsychotic is used for comorbid aggression (ODD, CD)

risperidone

which mood stabilizers can be used for comorbid aggression and/or ADHD (ODD, CD)

divalproex, lithium

which medications are used for ADHD and/or comorbid aggression in ODD or CD?

Methylphenidate > Amphetamine

Atomoxetine

what is reactive attachment disorder?

Consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers where the child rarely seeks comfort when distressed and when the child is comforted, they rarely respond.

When are reactive attachment disorder disturbances evident?

before 5 years of age

How does reactive attachment disorder present?

Minimal social and emotional responsiveness to others. Episodes of unexplained irritability, sadness, or fearfulness even during non-threatening interactions with adults. 

Children with reactive attachment disorder have experienced insufficient care by at least one of the following:

Social neglect/deprivation from lack of basic emotional needs for comfort, stimulation, and/or affection.

Repeated changes of primary caregivers that limit ability to form stable attachments.

Rearing in unusual settings that limit opportunities to form selective attachments.

Treatments for reactive attachment disorder:

Attachment-based therapy, CBT, and play therapy for younger children.

SSRIs, Mood stabilizers, Antipsychotics, Stimulants, Alpha-agonists

which SSRIs can be used to manage depression and anxiety, along with promote emotional regulation to assist in therapy for reactive attachment disorder?

fluoxetine and sertraline

which mood stabilizers can be used to regulate emotional volatility and aggression in reactive attachment disorder

lithium

which antipsychotic can be used for reactive attachment disorder if severe behavioral issues are present?

risperidone

Why are stimulants used for reactive attachment disorder?

they are effective if poor focus and hyperactivity

which alpha-agonists are useful for hyperactivity and impulsivity in reactive attachment disorder

clonidine and guanfacine

what are personality disorders?

Pattern of inner experience and behavior that diverges from the cultural norm and is expressed through two or more areas (cognition, affectivity, interpersonal functioning, or impulse control).

What are the environmental risk factors for personality disorders?

severe sustained childhood neglect and/or physical, verbal, sexual, or emotional abuse

what is cluster A in personality disorders?

paranoid, schizoid, schizotypal

what is cluster B in personality disorders?

antisocial, narcissistic, histrionic, borderline

what is cluster C in personality disorders?

avoidant, dependent, obsessive compulsive

how many “clusters” exist for personality disorders?

3

when is borderline personality disorder (BPD) diagnosed?

between 18-40 years old

facts regarding borderline personality disorder:

Premature death common due to risk of suicide (70-75% diagnosed with BPD have at least one deliberate act of self-harm, 9% rate of death by suicide)