Chapter 7: Posttraumatic Stress Disorder

Patricia A. Resick

Candice M. Monson

Shireen L. Rizvi

Trauma and Stressor-related Disorders

Posttraumatic Stress Disorder (PTSD)A disorder of nonrecovery (or stalled recovery) after a traumatic event-

must now specify if experienced, witnessed, or experienced indirectly.

Requires presence of specified numbers of symptoms in each of 4 broad categories which includes a total of 20 possible symptoms

Acute Stress Disorder (ASD)- 9 of 14 symptoms

-Subjective reaction of horror criteria eliminated for both disorders

SymptomsEpidemiologyBiological, cognitive, emotional, and behavioral componentsComorbidity factorsAssessmentTreatment

DSM-5 Diagnostic Criteria of PTSD

A. The individual must have experienced or witnessed a traumatic event*, learned about a traumatic event happening to a loved one, or been repeatedly exposed to details of traumatic events (not just media exposure).

* An event is considered traumatic if it involved (1) actual or threatened death, (2) serious injury, or threat to physical integrity (e.g., motor-vehicle accident, rape, threat with a weapon, natural disaster), or (3) sexual violence

NOTE: All of the symptoms of PTSD must have started or worsened after the traumatic event

B. The individual must exhibit at least one of the following intrusion symptoms:~ persistent and distressing memories of the trauma

~ recurrent distressing nightmares about the traumatic event

~ dissociative reactions (e.g., flashbacks)

~ intense psychological or physiological responses when exposed to cues

(internal or external) that resemble the trauma

DSM-5 Diagnostic Criteria of PTSD

C. The individual must exhibit at least one of the following avoidance symptoms*:

~ effortful avoidance of internal cues

~ efforts to avoid external reminders of the trauma, like places, people,

or situations.

*These symptoms reflect strategies that individuals use in order to reduce coming

into contact with events, places, thoughts, or emotions that remind them of the

traumatic event.

D. The individual must exhibit at least two of the following mood and cognitive symptoms: ~ numbing, amnesia, or inability to have positive feelings

~ strong negative emotions such as guilt, anger, or fear

~ distorted self-blame or erroneous blame of others who did not cause or

intend the event

~ negative beliefs about self, others, and the world as a consequence of the traumatic event, or feelings of detachment/estragement from others

~ anhedonia or lack of participation related to significant activities

DSM-5 Diagnostic Criteria of PTSD (cont)

E. The individual must exhibit at least two of the following physiological arousal and reactivity symptoms:

~ sleep difficulties

~ impairment in concentration

~ exaggerated startle response

~ hypervigilance

~ irritable or aggressive behavior

~ reckless or self-destructive behavior

F. All of these symptoms must be concurrently present for at least 1 month

G. Symptoms must:

a. be perceived as distressing

OR

b. cause functional impairment

DSM-5 PTSD Subtypes/Specifers

PTSD: Preschool subtype• For children younger than 6 years old

• Accounts for differences in PTSD presentation in young children

PTSD with prominent dissociative symptoms• For individuals who meet full criteria but also experience

persistent or frequent experiences of depersonalization or derealization

• Thought to be qualitatively different than PTSD without dissociation

PTSD specifier- with delayed expression (full criteria not met until 6+ months

Prevalence of PTSD

About 7% of the population will have had PTSD at some point in their lifetime

Increased prevalence rates (up to 20% to 30%) in specific trauma-exposed groups (e.g., in victims of sexual abuse or rape, natural disasters, war veterans)

Most people exhibit PTSD symptoms immediately following trauma exposure (delayed onset PTSD is very rare)

Less “personal” events that have a wider range of severity (e.g., natural disasters, accidents) are associated with lower rates of PTSD than more personally directed events (e.g., rape, molestation, assault, combat)

There is also a dose-response relationship such that the more traumatic events one experiences, the more likely one will develop PTSD symptoms

Gender Differences

Men More likely to report experiencing

a physical attack, being threatened with a weapon, being in an accident, or witnessing a trauma

Have more overall exposure to trauma (60.7% of men vs. 51.2% of women have experienced at least one trauma in their lifetime)

Women More likely to report rape,

molestation, neglect, or physical abuse

Are nearly 3 times as likely to have a lifetime diagnosis of PTSD (9.7% to 3.6%)

* However, recent studies of veterans deployed to Iraq or Afghanistan reported no gender differences in overall number of traumatic events during deployment or gender differences in rates of PTSD

* Rape is the single event most likely to result in PTSD among both men and women

* * *

Psychobiology and PTSD

Selected neurobiological systems implicated in PTSD:

Noradrenergic System• Increased noradrenergic activity in people with PTSD • Heightened norepinephrine reactivity to pharmacological and behavioral

challenge • Low baseline levels of neuropeptide Y (NPY): released with norepinephrine;

associated with anxiolysis (anti-anxiety) and cognitive-enhancement

Hypothalamic-Pituitary-Adrenal (HPA) Axis• HPA dysregulation is consistently associated with trauma exposure and PTSD

(e.g., Vietnam vets have enhanced CRF release)

Gamma-Amino Butyric Acid (GABA)• GABA is the brain’s primary inhibitory neurotransmitter• Reduced GABA action and baseline levels in patients with PTSD

Disinhibition of the amygdala via higher monoamine levels and subsequently disrupted PFC dysfunction

Cognition, Memory, and PTSD

Disruptions in cognition and memory are at the core of PTSD:

Problems remembering and forgetting traumatic events (e.g., someone with PTSD may have trouble intentionally accessing his or her memory of the event but have involuntary intrusions of parts of it)

Maladaptive cognitions (e.g., “Because one person assaulted me, that means no one can be trusted”)

Flashbacks, intrusive memories, amnesia, and fragmented memory

Altered beliefs about the self, the world, and others (e.g., self as incompetent; world as dangerous)

Disorganized narratives about the trauma with more sensory details and negative emotional content

Cognitive avoidance strategies (e.g., thought suppression)

Behavior, Emotion, and PTSD

Behavioral Factors Avoidance behaviors are key in PTSD

As in classical fear conditioning, the traumatic event becomes associated with other stimuli (e.g., certain sounds or smells), which then elicit conditioned emotional responses.

Avoidance of the conditioned stimuli reduces anxiety in the short term.

Following traumatic events, a pathological fear structure develops that is composed of feared stimuli, responses, and meaning elements (Cahill & Foa, 2007)

When the fear structure is triggered, cognitive, behavioral, and arousal anxiety result

Emotional Factors Traumatic events also become

associated with emotional stimuli (e.g., unpleasant emotions like fear, guilt, and shame)

Fear and anxiety play a large role in PTSD

But other emotions have also been implicated as central in PTSD: anger, shame, guilt, hopelessness, sadness, and humiliation

Comorbidity and PTSD

High rates of comorbidity:

Major depressive disorder found in 50% or more of PTSD cases

Generalized anxiety disorder and alcohol abuse/dependence are also common comorbidities

Rates of comorbidity range between 50% to 80% in military veterans

Personality and PTSD

Internalizing Subtype

* Tends to direct distress inwardly through shame, self-deprecating beliefs, anxiety, avoidance, depression, and withdrawal

* High rates of comorbid major depression, panic disorder, schizoid and avoidant personality disorder features

* Personality profile defined by high negative emotionality and low positive emotionality

* Hypersensitivity to negative evaluation

“Simple” Subtype

* (Low on both internalizing

and externalizing)

Externalizing Subtype

* Tends to outwardly express distress through antagonistic interactions with others, blaming others, and coping through acting out

* Tendency toward anger, aggression, impulsivity

* High rates of substance-related

disorders and cluster B personality disorder features

* Emotionally labile, overactive, fearless

* Feels chronically betrayed and mistreated by others

Evidence for three subtypes of PTSD:

Environmental Factors and PTSD

Social Support and Additional Life

Stress

Lack of social support is a major risk factor for PTSD among people exposed to trauma

Additional life stressors also a major risk factor for PTSD (e.g., family adjustment problems and problems with work or housing)

Conservation of Resources Theory

Traumatic stress sudden, rapid loss of resources that are most valued (e.g., trust in self and others, social support, perception of control, sense of well-being)

People with abundant personal, social, and financial resources will recover more quickly

People with depleted resources or people already facing additional life stressors are most at risk

Intimate Relationships

• Dysfunction in intimate relationships is associated with vulnerability to PTSD

• Individuals with PTSD are more likely to experience divorce, relationship discord, domestic violence

• Avoidance and numbing symptoms are implicated in relationship satisfaction

• Hyperarousal symptoms are associated with violence

Assessment

Assessment for PTSD must be careful and sensitive, determining: Whether a life event meets the seriousness requirement of a traumatic stressor The presence and severity of the 20 associated symptoms

Diagnostic interviews More time-consuming Most widely used: Clinician-Administered PTSD Scale (CAPS) (Blake et al., 1995)

Self-Report Measures Rely on participant’s judgment about what constitutes a traumatic event Some are limited to certain populations (e.g., Mississippi Scale for Combat-Related PTSD) Can be used as a screening tool in conjunction with a diagnostic interview For example PTSD Symptom Scale–Self-Report (PSS-SR)

Physiological Assessment Physiological reactivity to trauma cues is one of the criteria for PTSD A comprehensive assessment of PTSD should include psychophysiological testing (e.g., heart

rate and blood pressure response to combat-related sounds) However, psychotropic drugs and antisocial characteristics can alter physiological responses

Measures for the updated DSM-5 criteria have been developed and are currently being tested

Psychosocial Treatments

There have now been over 75 randomized controlled trials of psychotherapy for PTSD*

We have treatments that work with the majority of people with PTSD (40% to 80% fully remit)

Approximately 50% of individuals in intention-to-treat samples do not have a remission in their PTSD diagnosis as a result of treatment

*As of May, 2013

Psychosocial Treatments

Cognitive behavior therapy (CBT) has the largest body of research supporting its efficacy in treating PTSD

Most of these therapies propose that for therapy to work, the person must be able to activate the trauma memory, block the negative reinforcement that occurs with escape and avoidance behavior, and disconfirm erroneous beliefs through extinction of anxiety

Prolonged exposure (PE) - includes both imaginal and in vivo exposure techniques

Cognitive processing therapy (CPT) - a predominantly cognitive therapy for PTSD that includes some behavioral elements

Stress Inoculation Therapy (SIT) - one of the few cognitive behavior therapies that does not include any trauma-specific interventions

Generally, little evidence for any one (or any single element) of these therapies being more efficacious than any other

However, PE out-performs SIT at follow-up (Foa, Rothbaum, Riggs, & Murdock, 1991)

Psychosocial Treatments

Interventions with limited empirical evidence for treating PTSD

Eye Movement Desensitization and Reprocessing (EMDR)• No evidence supporting the specific efficacy of eye movements • Evidence that the active ingredients of EMDR are actually cognitive-behavioral in nature

Brief eclectic psychotherapy (BEP) - Combines cognitive-behavioral and psychodynamic approaches and includes: • (1) psychoeducation about PTSD, (2) imaginal exposure, (3) writing tasks and memorabilia

aimed at uncovering difficult feelings, (4) meaning and integration, and (5) farewell ritual• Has been shown to be efficacious with police officers and outpatients with a range of trauma

Narrative exposure therapy (NET)• Patients provide a detailed chronological report of their own biographies, with a special focus on

traumatic experiences. • Report is recorded in written form and read during sessions with the goal of developing a

coherent narrative of the traumatic event and the habituation of emotional responses to reminders of the traumatic event

Cognitive-behavioral conjoint therapy for PTSD (CBCT) • 15-session, manualized therapy that also addresses interpersonal functioning• Evidence for improved: 1) relationship functioning and 2) psychological functioning in partners

*As of May, 2013

Psychopharmacological Treatments

Currently, only sertraline and paroxetine (SSRIs) have received indication from the FDA for the treatment of PTSD.

Other antidepressants: Two controlled trials support the efficacy of venlafaxine, a serotonin norepinephrine reuptake

inhibitor (SNRI), in the treatment of PTSD

Antiadrenergics (Drugs Acting on the Epinephrine and Norepinephrine Systems) Prazosin reveals improvements in trauma-related nightmares and other PTSD symptoms A single randomized controlled trial (RCT) of guanfacine found no superiority over placebo in

veterans with PTSD

Mood stabilizers and Atypical Antipsychotics Limited support; decreased reexperiencing and avoidance symptoms of PTSD with lamotrigine

(Hertzberg et al., 1999); Risperidone superior to placebo (Padala et al., 2006)

Augmentation With Partial NMDA Agonist D-cycloserine (DCS) improved anxiety symptoms in PTSD when used as augmentation to other

PTSD medications (Heresco-Levy et al., 2002).

GABA-ergic Agonists (Antianxiety Medication) No evidence for efficacy

PTSD Treatments

Discontinuation of medication is associated with relapse of PTSD symptoms

In psychotherapy trials, long-term follow-up with PTSD patients suggests maintenance of gains across different types of therapy

Results from research favor psychotherapy over medications for treating PTSD, but many medications can provide some relief for some symptoms

Summary and Future Directions

Most people experience traumatic events in their lives that are serious. Nevertheless, with time, the majority of people go on to recover.

The more traumas that people experience, the more likely they are to have symptoms. A strong dose-response relationship.

PTSD treatment may be complicated by substance abuse, chronic pain, severe depression, and personality disorders.

PTSD is maintained over time by avoidance and numbing. People often refuse to seek treatment even when they know it is available, and show high dropout rates (20% to 40%).

Most of the research and treatment focus has been on fear and anxiety to the exclusion of other important emotions, such as anger, sadness, shame, or horror.

Current theories of PTSD are concerned with memory, emotions, and cognition. More research is needed in these areas.

Future research needed in the underlying biology of PTSD (e.g., brain structures, neurotransmitters, and hormones), which will help us understand the interaction of biology, individual differences, and environment in PTSD