ideas and images

↓ 

terror, horror, helplessness

↓ 

amygdala activation

↓ 

traumatic stress cascade

Describe amygdala function and development

• function
  • most efficient in states of alarm
  • no sense of rememberance
  • implicit memory (mood and body memory)- as images, body sensation, emotional states
• development- mature from birth

• function
  • narrative memory of events (verbal memory)
  • sense of remembrance
  • explicit memory
  • shut down in states of alarm
• development- matures at age 2-3

visceral sensation

five senses

• periaqueductal gray activation → increase in enkephalons (equiv. to morphine does)
  • lead to dissociation, freeze, analgesia
• pontine reticular formation → increase startle motor reflex
• hypothalmus release CRF → pituitary release ACTH → adrenals release cortisol (negative feedback to pituitary, hypothal., amygdala)
• deactivate hippocampus and Broca's area language system
• stimulates lateral hypothalamus → increase symp. NS discharge into muscles and viscera
• stimulate locus coeruleus → increase norepinepherine release into cortex

• hyperactive amygdala
• hypoactive anterior cingulate cortex and hippocampus
• structural damage within hipocampus
• weak cortisol response to stress
• chronic and excessive release of CRF within amygdala sustained by:
  • loss of inh. control by ant. cingulate cortex
  • loss of inh. control by hippocampus
  • insufficient negative feedback from serum cortisol response to stress

• hypervigilance and excessive reactivity
• memory impairment
• inability to articulate experience in language
• impaired abstract reasoning

• prefrontal executive functions systems
• cortical language systems
• hippocampal memory systems

% of people who develop PTSD who experience traumatic event

• severity of traumatic events
• prior traumatic events
• absensce of protective and affirming social support in response to raumatic event
• for kids- disrupt familiar places in routines through traumatic event
• early onset of depressed mood (best indicator)
• dissociative symptoms during traumatic event (emotional numbing, feeling outside body, amnesia) 
• low plasma cortisol at time of truma
• high heart rate immediately after trauma

• provide food, shelter, physical comfort, safetyl
• facilitate communication with family and friends
• reduce physiological arousal
• educate about recovery, available resources, coping strategies
• spiritual, religious, existential support
• avoid prolonged benzodiazepines
• recognize those at risk for PTSD and follow up

DSMV criteria for PTSD

• exposure to traumatic event with symptoms enduring longer than one month for each of the following
  • traumatic event persistently re- experienced
  • persistent avoidance of stimuli associated with traumatic event and numbing of general responsiveness
  • persistent symptoms of hyperarousal not present before traumatic event

• GI symptoms
• CV symptoms
• neurological symptoms
• musculoskeletal symptoms
• headaches
• low back pain
• respiratory symptoms

• build repertoire of skills for de-arousing body
  • breathing and muscle relaxation techniques
  • grounding techniques
• plan graduated exposure to traumatic stimuli until autonomic fear responses extinguish
• reconstruct coherent trauma narrative and personal meaning

• first line- Sertraline, Paroxetine, Fluoxetine (SSRI antidepressants)
• second line- Nefazodone, Venlafaxine
• third line- tricyclic, MAO inh., antidepressants
• augment SSRI with atypical antipsychotic (Olanzapine, Quetiapine, Risperidone)
• target specific symptoms (nightmares, excessive startle, irritability, hallucinations)