ASD and PTSD Psych Exam 2 IPAP 3 16

Intense or prolonged psychological distress at exposure to

internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Intense or prolonged psychological distress or marked physiological reactions in response to

internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Negative Mood

Acute Stress Disorder includes symptoms of

intrusion, dissociation, negative mood, avoidance, and arousal

Posttraumatic Stress Disorder: Overview

is a disorder of recurrent symptoms brought on by exposure to a traumatic event. The initial response includes fear and helplessness. A person persistently relives the event, and tries to avoid being reminded of it.

Focused physical exam only to rule out

medical causes for any physical symptoms

Acute Stress Disorder: Treatment Second line therapy

pharmacotherapy; Benzodiazepines, short term only (2 weeks max - longer puts pt at higher risk of PTSD)

Experiencing repeated or extreme exposure to

aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Get a thorough history of current symptomatology in a

timeline format

Acute Stress Disorder: Evaluation Need to know nature of the inciting trauma, but do not judge whether the trauma is

"bad enough" to be causing symptoms

Post Traumatic Stress Disorder: Diagnostic Criteria F Duration of the disturbance (Criteria B, C, D, and E) is more than

1 month.

Acute Stress Disorder: Diagnostic CriteriaC. Duration of the disturbance (symptoms in Criterion B) is

3 days to 1 month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.

B. In the presence of 9 (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred

Acute Stress Disorder Diagnostic Criteria is met

Long Term Issues associated with Post Traumatic Stress Disorder

Alcoholism, Relationships, Adjustment, Suicide, Isolation, Depression

Dissociative Symptoms

An altered sense of the reality of one's surroundings or oneself (e.g., seeing oneself from another's perspective, being in a daze, time slowing). Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Post Traumatic Stress Disorder: Diagnostic Criteria C; Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by 1 or both of the following:

Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Acute treatment of Post Traumatic Stress Disorder

Basic symptom management, Sleep disturbance/insomnia (Ambien, Seroquel), Pain management. Irritation/excessive arousal/anger; Avoid things like - caffeine, nicotine, 24 hour cable news channels. Facilitate spiritual and social support

Acute Stress Disorder: Overview

Characterized by acute stress reactions that may occur in the initial month after a person is exposed to a traumatic event. Sometimes confused with old DSM-IV diagnosis of adjustment disorder

Persistent symptoms of Post Traumatic Stress Disorder

Consultation, evacuation, Continued treatment with yourself or mental health specialists, Continue to assess and reassess symptoms. YOU (the PA) can start medications if PTSD seems likely.

Medications for Post Traumatic Stress Disorder

SSRI (selective serotonin reuptake inhibitor) - mainstay of treatment (consider first-line) (Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil)) SNRI (serotonin and norepinephrine reuptake inhibitors)Venlafaxine (Effexor)

Post Traumatic Stress Disorder Hyperarousal (two of the following):

Difficulty falling asleep, Irritability or outbursts of anger, Difficulty concentrating, Hypervigilance, and Exaggerated startle response. Must occur longer than 1 month; otherwise it is diagnosed as Acute stress disorder.

1 (or more) of the following ways must be present for diagnosis of Acute Stress Disorder:

Directly experiencing the traumatic event(s). Witnessing, in person, the event(s) as it occurred to others. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).

Post Traumatic Stress Disorder: Diagnostic Criteria A. Exposure to actual or threatened death, serious injury, or sexual violence in 1 (or more) of the following ways:

Directly experiencing the traumatic event(s). Witnessing, in person, the event(s) as it occurred to others. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

Avoidance Symptoms

Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Post Traumatic Stress Disorder Avoidance/numbing (three of the following)

Efforts to avoid thoughts/conversations associated with the event, Avoid activities/places/people associated with the event, Inability to recall important aspects of the trauma, Diminished interest in significant activities, Feeling detached from others, Restricted range of affect, and Sense of foreshortened future

Acute Stress Disorder Diagnostic Criteria A.

Exposure to actual or threatened death, serious injury, or sexual violation

Post Traumatic Stress Disorder: Diagnostic Criteria D; Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by 2 (or more) of the following:

Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined").

Post Traumatic Stress Disorder Facts Not all events lead to Post Traumatic Stress Disorder such as

Interpersonal Violence (Rape, Torture, Assault), Witnessed events (Traumatic and unnatural deaths, Learning a loved one was involved)

Post Traumatic Stress Disorder Re-experience the traumatic event (one of the following):

Intrusive thoughts/perceptions/images, Distressing dreams, Acting or feeling that the event was recurring, Intense psychological distress at symbolic cues, and Physiologic reactivity upon exposure to those cues

Post Traumatic Stress Disorder Overview: After witnessing/experiencing a traumatic event;

Involve actual or threatened death or serious injury, or threat to personal integrity. Response involves fear, helplessness or horror.

Post Traumatic Stress Disorder: Diagnostic Criteria E; Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by 2 (or more) of the following:

Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. Reckless or self-destructive behavior. Hypervigilance. Exaggerated startle response. Problems with concentration. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Early treatment of Post Traumatic Stress Disorder

Not all Acute Stress Disorder becomes PTSD. Early intervention can prevent this. Identify people with symptoms early. Get them treated quickly

Post Traumatic Stress Disorder Risk factors of persons most likely Post-traumatic risk factors:

Ongoing life stress, Lack of positive social support, Bereavement or traumatic grief, Major loss of resources, Negative social support, Poor coping skills, and Home concerns

Post Traumatic Stress Disorder Risk factors of persons most likely Pre-traumatic factors:

Ongoing life stress, Lack of social support, Young age, Pre-existing psych illness, OR substance misuse, Previous traumatic event, Hx of PTSD, and Personality disorder

Post Traumatic Stress Disorder: Diagnostic Criteria D continued

Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). Markedly diminished interest or participation in significant activities. Feelings of detachment or estrangement from others. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Screening: Who and when and how

Persons exposed to trauma. All new patients screen for symptoms of Post Traumatic Stress Disorder and then annually or as needed. Personnel with declining performance.

Key Points on Post Traumatic Stress Disorder

Post Traumatic Stress Disorder has very characteristic features, Not a disease of weak character, but biological change, Early Treatment helps prevent chronic disease

Methods for screening Post Traumatic Stress Disorder:

Primary care Post Traumatic Stress Disorder screen, Post Traumatic Stress Disorder Brief screen, Short screening scale, and Post Traumatic Stress Disorder checklist

Intrusion Symptoms

Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.

Post Traumatic Stress Disorder: Diagnostic Criteria B. Presence of 1 (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Post Traumatic Stress Disorder Risk factors of persons most likely Peri-traumatic risk factors:

Severe trauma, Physical injury to self or other, Type of trauma, High perception of threat, and Mass trauma

Arousal Symptoms

Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects. Hypervigilance. Problems with concentration. Exaggerated startle response.

Treatment Therapy for Post Traumatic Stress Disorder

Symptoms represent psychological response to stress/trauma, not character flaw, Trauma focused training (Cognitive restructuring, Stress inoculation training), Imagery rehearsal therapy, Psychodynamic, Hypnosis, Group therapy

Post Traumatic Stress Disorder: Diagnostic Criteria H The disturbance is not attributable to the physiological effects of

a substance (e.g., medication, alcohol) or another medical condition.

Post Traumatic Stress Disorder: Diagnostic Criteria G The disturbance causes

clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Acute Stress Disorder: Diagnostic Criteria D. The disturbance causes clinically significant

distress or impairment in social, occupational, or other important areas of functioning.

ASD criteria does not apply to

exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

Criterion A4 does not apply to

exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

Persistent inability to experience

positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Some patients who experience Acute Stress Disorder go on to experience

posttraumatic stress disorder (PTSD), which is diagnosed only after four weeks following exposure to trauma.

Acute Stress Disorder: Treatment First line therapy

psychotherapy (cognitive behavioral therapy), which may be delayed to allow for treatment of immediate injuries (physical, suicidal ideation, etc.)

Marked physiological reactions to internal or external cues that

symbolize or resemble an aspect of the traumatic event(s).

Acute Stress Disorder: Diagnostic Criteria E. The disturbance is not attributable to

the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if

the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if

the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.