Behavioral Med Trauma and Stress Related Disorders

PTSD

post traumatic stress disorder

the complex somatic, cognitive, affective, and behavioral effects of psychological trauma

PTSD characteristics

intrusive thoughts

nightmares and flashbacks

avoidance of trauma reminders

hypervigilance

sleep disturbance

MC associated traumatic event w PTSD

sexual assault

PTSD and acute stress disorder most important risk factors

severity, duration, and proximity of a person's exposure to the actual trauma

stressor

the prime causative factor in the development of PTSD

the stressor alone does not cause the disorder

response involves intense fear or horror

psychodynamic factors

the trauma reactivates a previously dormant, yet unresolved psychological conflict

cognitive behavioral factors

person cannot process or rationalize trauma

alternating periods of acknowledgement and blocking as a way to cope

biological factors

hypothalamic-pituitary-adrenal axis may be hyperactive in these individuals

increased activity of ANS

PTSD and acute stress pathophysiology

decreased volume of hippocampus, left amygdala, anterior cingulate cortex

increased NE

chronically decreased glucocorticoid levels

failure of left hemispheric function

genetics

previous exposure to trauma

PTSD cardinal features

traumatic event experience

intrusion symptoms

avoidance symptoms

negative cognition/mood changes

arousal or reactivity

PTSD DSM-5 criteria

must have some element of cardinal features and be at least 6yo

PTSD criterion A

traumatic event (at least one)

MVA, combat/military operations, home invasion/robbery, rape/SA, life-threatening illness

may be victim or witness

may be unable to identify specific event

PTSD criterion B

intrusion symptoms (at least one) *hallmark

re-experiencing symptoms, unwanted intrusive memories, flashbacks, nightmares, occasional thoughts, assoc w significant psychological distress/fear/panic, autonomic arousal

may be triggered or spontaneous

PTSD criterion C

avoidance symptoms (at least one)

avoid stimuli associated w event- internal thoughts/feelings, activities, people, situations, place where trauma occurred

leads to functional impairment

PTSD criterion D

cognitive distortions (at least 2)

persistent and exaggerated negative beliefs or expectations

distorted cognitions about the cause or consequences

persistent negative emotional state

markedly diminished interest/participation in activities,

feelings of detachment/estrangement from others

persistent inability to experience positive emotions

PTSD criterion E

arousal and reactivity changes (at least 2)

irritability, aggression, reckless/self-destructive, sleep disturbances, feeling on edge, easily startled, poor concentration

must have started after traumatic event

PTSD criterion F

duration

must persist more than 1 month

PTSD criterion G

functional significance

symptoms must cause clinically significant distress or impairment in social, occupational, other areas

PTSD criterion H

not due to substance use or other medical condition

PTSD dissociative symptoms

subtype of PTSD, higher levels of impairment, comorbidity, suicide

depersonalization, derealization, dissociative amnesia

PTSD psychiatric comorbidities

50% have 3 or more psych comorbidities

depressive disorder, anxiety disorder, SUD, personality disorder, somatic symptoms

PTSD medical comorbidities

CV and lung disease + associated risk factors (smoking, HTN, DM, etc), autoimmune and endocrine disease, dementia, parkinson's disease, TBI, IBS

when assessing for PTSD ask about

suicidal ideation, substance use disorder, and other medical conditions

PTSD checklist for DSM-5

20 item self-report tool

used for screening, provisional diagnosis, and monitoring response to treatment

clinician-administered PTSD scale (CAPS-5)

gold standard

30-item structured interview

used to make current diagnosis of PTSD, make lifetime diagnosis of PTSD, assess PTSD symptoms over the past week

acute stress disorder

intense and unpleasant reaction that develops in the weeks following a traumatic event

last

PTSD can develop ___ to ___ after the trauma

1 week - 30+ years

PTSD good prognostic indicators

rapid onset of symptoms

short duration (

PTSD and acute stress treatment focuses on

support, encouragement to discuss event, education about a variety of coping mechanisms

first line treatment for PTSD and acute stress

trauma focused therapy

CBT (most studied), exposure therapy, EMDR

EMDR

eye movement desentitization and reprocessing

choosing among trauma-focused therapies for PTSD is based on

patient presentation, patient preference, therapist expertise, access to therapy

non-trauma focused psychotherapies

mindfullness-based stress reduction

present-centered therapy

mindfullness-based stress reduction

teaches patients to attend to present moment in non-judgmental manner

present-centered therapy

focuses on increasing adaptive responses to current life stressors and difficulties that are directly or indirectly related to trauma or PTSD symptoms

first line medical therapy for PTSD and acute stress

sertraline and paroxetine

buspirone may also be effective

other pharmacotherapy options for PTSD and acute stress

TCAs- imapramine, amitriptyline

anticonvulsants- carbamazepine, valproate

postpartum blues

within 6 weeks of delivery

mood lability, sadness, dysphoria, treafulness

postpartum blues is attributed to

fluctuating hormones, stress of childbirth, awareness of increased responsibility of motherhood

postpartum blues treatment

no professional treatment needed

short duration, mild symptoms, limited effect on functioning

postpartum unipolar depression risk factors

hx of depression, depression during pregnancy, high levels of postnatal stress

USPSTF recommends screening ____ for postpartum unipolar depression

all patients

use Edinburgh Depression Scale

postpartum unipolar depression secondary risk factors

postpartum depression

same criteria as major depressive episode within 6 weeks of delivery

"SIG E CAPS"

sleep disturbance, interest decreased, guilt/feelings of worthlessness, energy decreased, concentration problems, appetite/weight changes, psychomotor agitation or retardation, suicidal ideation

postpartum depression worsening symptoms

difficultly breastfeeding, difficulty forming attachment with newborn, inability to return to work

postpartum depression had a ___ chance of recurrence

50%

postpartum depression adverse consequences

increased risk of not breastfeeding, impaired bond with infant, poorer health care of children, poor sleep positioning, less likely to receive infant and childhood vaccinations, suicide, infanticide (rare)

treatment of postpartum depression

CBT

SSRIs- sertraline or paroxetine preferred if breastfeeding

postpartum psychosis

psychotic disorder that occurs in women who have recently delivered a baby (often within days)

rapid onset of depression, delusions, thoughts of harming self or infant

postpartum psychosis has close relationship with

bipolar disorder and MDD

early symptoms of postpartum psychosis

fatigue, insomnia, restlessness, tearfulness, emotional lability

later symptoms of postpartum psychosis

suspiciousness, confusion, incoherence, irrational statements, obsessive concerns about baby;s health

extreme cases will deny birth, harm baby

treatment of postpartum psychosis

lithium, valproic acid, carbamazepine

refer for in depth treatment plan or inpatient therapy (harm to self or others)

develop close follow up plan

adjustment disorder

a stress-related condition where a person has difficulty coping with or adjusting to a specific life event or change

tied to acute and chronic stress

adjustment disorder causes/triggers

death of a loved one, divorce, general life changes, illness, moving, unexpected catastrophe, financial concerns, family problems, school problems, sexuality issues

adjustment disorder DSM-5 criteria

A. development of emotional/behavioral symptoms in response to an identifiable stressor w/in 3 months

B. marked distress out of proportion to the intensity of the stressor; causes significant functional impairment

C. does not meet criteria for another mental disorder or exacerbation of preexisting mental disorder

D. symptoms do not represent normal bereavement

E. symptoms doe not persist for more than 6 months

adjustment disorder DSM-5 criteria specifiers

with depresssed mood, with anxiety, or with mixed anxiety-depression

with conduct disturbance or mixed disturbance of emotions and conduct

unspecified

adjustment disorder clinical features

defiance or impulsivity

nervouseness

depression or withdrawal

somatic symptoms

adjustment disorder treatment

CBT- primary treatment

SSRIs, SNRIs, benzodiazepines, anxiolytics used to treat debilitating symptoms