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Ministry of Health of Ukraine

Bukovynian State Medical University


“Approved”

on the methodical meeting

of the Department of neurology, psychiatry

and medical psychology nm. S.M.Savenko

“____” ___________ 2009 (Report № __).

Chief of the Department

_______________________

Professor V.M. Pashkovsky


Methodical INSTRUCTION

for 4-th year students of medical faculty №2

(the speciality “medical affair”)

for independent work during preparing to practical class


Theme 23: post-traumatic stress disorder.


MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY


Topical module 5. Neurotic, stress-related and somatoform

disoders.


Сhernivtsi, 2009


1. Actuality of theme:

Post-traumatic stress disorder is an intense, prolonged, and of­ten delayed reaction to a stressful event. Usually the event is so intense as to be overwhelming, so that the person cannot complete the normal sequence of psychological changes that follow exposure to a stressor (described in the previous-section). Examples of such extreme stressors are natural disasters such as floods and earthquakes, manmade calamities such as major fires, serious transport accidents, or the effects of war, and serious assaults on the person such as rape or mugging. Not everyone develops post­traumatic stress disorder after such experiences. The risk is higher amongst three groups: those who have experienced the most dis­tressing aspects of the disaster (for example being trapped among the dying), children and old people.


2. Duration of practical classes - 2 hours.


3. ^ EDUCATIONAL PURPOSE

3.1. To know:

  1. The definition of notion post-traumatic stress disorder.

  2. The reasons post-traumatic stress disorder.

  3. Psychological and mental disorder in persons called at extreme situations.

  4. Clinical manifestations of post-traumatic stress disorder.

  5. Treatment of post-traumatic stress disorder.

  6. Prophylactic of post-traumatic stress disorder


3.2. Able:

  1. To determine clinical syndromes of post-traumatic stress disorders .

  2. To diagnose and conduct differential diagnosis of post-traumatic stress disorder.

  3. To give urgent help at post-traumatic stress disorder after extreme situations.

  4. To use methods of treatment of post-traumatic stress disorder.

  5. To conduct prophylactic of post-traumatic stress disorder.


3.3. To capture practical skills:

  1. To give urgent help at post-traumatic stress disorder.

  2. To give urgent help after extreme situations.



^ 4. INTERSUBJECT INTEGRATION (base level of preparation).


Names of previous disciplines

Skills are got

1. Anatomy of human


2. General and medical psychology.


3. Normal and pathologic physiology.

1. To know structure of brain.


2. Determine type personality. To know methods examinations of personality.

3. Determine type HNA.


5. Advices to students.


    1. ^ CONTENTS OF THEME.

Etiology and Pathogenesis

Although a tragic loss or other life event may be the precipitating stressor, individual predisposition may play a role in development of posttraumatic stress disorder. The victim’s mental catalog of life experi­ences must be expanded to accommodate the traumatic event. Until this adjustment has been made, the vic­tim’s “memory” of the traumatic event retains in the present what belongs in the past even after the im­mediate strain is over. Reliving the event maintains the supply of intrusive ideas and feelings whether the victim is awake or asleep. Efforts to avoid such painful experiences lead to narrowing of interests, worsening of the quality of life, and formation of other symptoms such as denial and numbing. Phases of denial may alternate with periods of intrusion as the patient works through the stress and eventually completes the stress cycle.

Situations that remind the victim of a stressful event and produce states of mind similar to those experienced at that time tend to rekindle posttraumatic stress disorder, even after some time has passed. Post­traumatic stress disorder may itself modify the person­ality, so that in chronic cases that come to therapy there is much to be done after dealing with the reaction to the stressful event itself.

Clinical Picture. Post-traumatic stress disorder has three groups of features. The first is a variable combination of symptoms of per­sistent anxiety, irritability, insomnia, and poor concentration. Sometimes there are attacks of panic or episodes of aggression. The second is a group of persisting defences of avoidance and denial, including avoidance of reminders of the events, difficulty in recall­ing the events at will, brief but intense intrusive imagery of the events (“flashbacks”), and recurrent distressing dreams of the events. The third group, which is reported by some patients, includes detachment, inability to feel emotion (“numbness”), and di­minished interest in activities. Despite these indications of persist­ing coping responses and defence mechanisms, the person may still have severe anxiety or depression. Anxiety increases further when the person has flashbacks or is reminded of the traumatic event. Sometimes there are additional maladaptive coping responses of persistent histrionic or aggressive behaviour, or excessive use of alcohol or drugs.

Post-traumatic stress disorder may be a direct continuation of the acute response to stress, or may follow an interval of days or occasionally months (rarely more than six months). The disorder usually resolves within months, but may persist for years.

In ICD-10 the post-traumatic stress disorder (PTSD) is classi­fied in the section F40-F48 together with neurotic, stress-related and somatoform disorders and coded depending on the prevailing syndrome.

^ F43.1. Post-traumatic stress disorder. Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0). (From ICD-10).


^ Diagnostic criteria for posttraumatic stress disorder.

A. Existence of a recognizable stressor that would evoke signifi­cant symptoms of distress in almost everyone.

B. Reexperiencing of the trauma as evidenced by at least one of the following:

(1) Recurrent and intrusive recollections of the event.

(2) Recurrent dreams of the event.

(3) Sudden acting or feeling as if the traumatic event were re­curring, because of an association with an environmental or ideational stimulus.

C. Numbing of responsiveness to or reduced involvement with the external world, beginning some time after the trauma, as shown by at least one of the following:

(1) Markedly diminished interest in one or more significant activities.

(2) Feeling of detachment or estrangement from others.

(3) Constricted affect.

D. At least 2 of the following symptoms that were not present before the trauma:

(1) Hyperalertness or exaggerated startle response.

(2) Sleep disturbance.

(3) Guilt about surviving when others have not, or about be­havior required for survival.

(4) Memory impairment or trouble concentrating.

(5) Avoidance of activities that arouse recollection of the traumatic event.

(6) Intensification of symptoms by exposure to events that symbolize or resemble the traumatic event.


Assessment should include the nature and duration of the symp­toms, the previous personality, and the psychiatric history. If the trau­matic event has included injury to the head (for example in an assault or transport accident) neurological examination should be carried out to exclude a subdural hematoma or other forms of injury.

^ Differential Diagnosis

Head injuries, including mild concussions that may have residual long-term effects on mood and concentration, must be considered in the differential diagnosis. Malnutrition during extended stressful periods may lead to prolonged organic brain syn­drome. Anxiety disorders, depressive illness, or organic mental disorders may be present, and these diagnoses should be made along with the diagnosis of posttraumatic stress disorder. If the stressor is not severe enough to meet the criteria for duration and onset, the diagnosis of adjustment disorder may be made even though the symptoms may be essentially the same. If “reliving” of the event is a conspicuous presenting feature, however, a diag­nosis of posttraumatic stress disorder is more appropriate.

Treatment. If the condition is of recent onset, the patient may need no more than the treatment described above for an acute re­action to stress, namely an opportunity to recall the stressful experiences and to express the associated emotions to an understand­ing and reassuring person. A few doses of an anxiolytic drug may be needed to calm the person, and a hypnotic drug may be required for a few nights to restore sleep. This simple but essential early care is best carried out, at the earliest possible stage, by the gen­eral practitioner or the specialist treating any associated physical injury. Sometimes the stressful events have to be talked about many times (“worked through”) before the symptoms begin to subside. In such cases, the doctor may arrange for counselling by a nurse or other staff member with appropriate skills.

When the disorder is longstanding, it is more difficult to treat and often requires specialist help. The same general approach is used: in a series of interviews the patient is provided with emo­tional support and is encouraged to recall, reexperience, and work through the emotion associated with the events. Even with skilled treatment, the response of chronic cases is often limited.


^ 5.2. Theoretic QUESTIONS:

1. The definition of notion post-traumatic stress disorder.

2. The reasons post-traumatic stress disorder.

3. Psychological and mental disorder in persons called at extreme situations.

4. Pathogenesis post-traumatic stress disorder.

5. Clinical manifestations of post-traumatic stress disorder.

6. Diagnosis and differential diagnosis of post-traumatic stress disorder.

7. Treatment of post-traumatic stress disorder.

8. Prophylactic of post-traumatic stress disorder.

9. Organization and giving medical-psychological aid of persons called in extreme situations.


^ 5.3. Practical tasks on the class:

1. To collect anamnesis, clinical psychopathological examination of patients with post-traumatic stress disorder.

2. Make up plan of examination and treatment of patient with post-traumatic stress disorder.

3. To solve tests and tasks.


5.4. Material for self-contrrol.


A. Questions of self-controls:

1. The definition of notion post-traumatic stress disorder.

2. The reasons post-traumatic stress disorder.

3. Psychological and mental disorder in persons called at extreme situations.

4. Pathogenesis post-traumatic stress disorder.

5. Clinical manifestations of post-traumatic stress disorder.

6. Diagnosis and differential diagnosis of post-traumatic stress disorder.

7. Treatment of post-traumatic stress disorder.

8. Prophylactic of post-traumatic stress disorder.

9. Organization and giving medical-psychological aid of persons called in extreme situations.

10. Urgent help at post-traumatic stress disorder


B. TESTS:

1. Post-traumatic stress disorder appears after:

A. Conflict in family

B. Extreme situations

C. Drug abuse

D. Injury of head

E. All above mentioned

2. Specific clinical signs of post-traumatic stress disorder are:

A. Karl Jasper’s syndrome

B. Kandinski-Clerambault’s syndrome

C. Korsakoff’s syndrome

D. Paranoid syndrome

E. Reexperiencing of the trauma

3. Diagnostic criteria of post-traumatic stress disorder are:

A. Inability to feel emotion

B. Intrusive imagery of the events

C. Insomnia

D.Trouble concentrating

E. All above mentioned

4. During what period post-traumatic stress disorder does appear:

A. From few days to few weeks

B. From few months to few years

C. From few weeks to half years

D. From few hours to few days

E. From few weeks to two years

5. For treatment of post-traumatic stress disorder used all except:

A. Anxiolytic

B. Soporific

C. Antidepressants

D. Psychostimulants

E. Psychotherapy

6. What sign is specific for pshychogenic psychosis?

A. Euphoria

B. Fear

C. Melancholy

D. Obsession

E. Compulsion


7. Clinical picture of post-traumatic stress disorder includes:

A. Vegetative disoders

B. Disoders of mood

C. Disoders of bechaviour

D. All right

E. All wrong

8. Clinical symptoms of depressive syndrome include all signs, except:

A. Increased of movement

B. Retarded thinking

C. Cloudiness of consciousness

D. Suicidal thinking

E. Delusion of being guilty and self-condemnation

9. What measures are most effective for treatment reactive depression?

A. Psychotherapy and antidepressants

B. Psychotherapy and anxiolytic

C. Physiotherapy and psychotherapy

D. Antidepressants and neuroleptics

E. Tricycle antidepressants and inhibitors MAO

10. Clinical symptoms of affective-shock reactions include all next signs, except:

A. Appear during catastrophe

B. Presence cloudiness of consciousness

C. Behaviour is infantile and foolish

D. Patients are dangerous for surrounding people

E. Prognosis – full recovery


^ 6. RECOMMENDED LITERATURE IS:

6.1. Basic:

  1. Clinical Psychiatry from Synopsis of Psychiatry by H.I.Kaplan, B.J.Sadock. – New York: Williams @ Wilkins. – 1997.

  2. Psychiatry. Course of lectures. – Odessa: The Odessa State Medical University. – 2005. – 336 p.

  3. Lectures.

  4. Internet resource.

6.2. Additional:

  1. Морозов Т.В., Шумский Н.Г. Введение в клиническую психиатрию. – Н.Новгород: Изд-во НГМА, 1998.

  2. Попов Ю.В., Вид В.Д. Современная клиническая психиатрия. – М., 1997.

  3. Сонник Г.Т. Психіатрія: Підручник / Г.Т.Сонник, О.К.Напрєєнко, А.М.Скрипніков. – К.: Здоров’я, 2006.     


Prepared by assistant S.D.Savka


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