POST TRAUMATIC STRESS DISORDER

PRESENTED BY:DR.A.GODSON,MD

INTRODUCTION

• Disorder driven by pathogenic memories of past danger.

• Symptoms must last for more than a month • Acute stress disorder, which occurs earlier

than PTSD

EPONYMS OF PTSD • Civil War-Irritable heart• World War I-shell shock

/Effort syndrome• World war II – combat stress

syndrome• Vietnam War- brought the

concept of PTSD.• Gulf war syndrome• PTSD entered the DSM-III in

1980

Common feature shared by all syndromes

• Fatigue, fainting• Shortness of breath,• Palpitations, • Headache, dizziness,• Excessive sweating, • Disturbed sleep, • Difficulty in

concentration• Forgetfulness

EPIDEMIOLGY

• Lifetime prevalence -8 percent in general population

• 5 to 15 percent -subclinical forms of the disorder.

• Among high-risk groups -5 to 75 percent. • 10 to 12 percent among women • 5 to 6 percent among men.• Higher in women, single, divorced, widowed,

socially withdrawn, of low socioeconomic level

• Sexual assault-higher impact• Sudden unexpected death

of a loved one and road traffic accidents

• Men -more traumatic events

• Women - higher impact events.

COMORBIDITY

• Depressive disorders• Substance-related disorders• Anxiety disorders • Bipolar disorders

ETIOLOGY

Stressor

• Prime causative factor• Stressors of human design-rape and violent

assault, are usually more pathogenic • Sudden, unexpected, and life-threatening

events• Disasters related

Risk factors for being exposed to trauma

• Less than a college education• Being male • History of childhood conduct

problems• Family history of psychiatric

illness • Extroverted• More neurotic

Risk factors for PTSD Among those exposed to trauma

• Female, neuroticism• Lower social support• Lower IQ• Pre-existing psychiatric

illness • Family history of mood,

anxiety, or substance abuse disorders

• Neurological soft signs

PREDICTORS• Previous exposure to trauma• Peritraumatic responses• Negative interpretations of one's acute

responses• Borderline, paranoid, dependent, or antisocial

personality disorder traits• Presence of childhood trauma• Inadequate family or peer support system• Recent stressful life changes• Recent excess alcohol intake

GENETICS• 1/3rd of variance in

symptoms is genetic• Trauma exposure-little or

no effect on measures of IQ &neurocognitive functioning

• Similarity in the test scores between co-twins implies genetic influence on cognitive performance

• Above average cognitive ability -protect

Psychodynamic Factors• Trauma has reactivated a previously quiescent, yet

unresolved psychological conflict• The subjective meaning of a stressor may determine its

traumatogenicity. • Traumatic events can resonate with childhood traumas. • Inability to regulate affect can result from trauma. • Somatization and alexithymia may be among the after

effects of trauma. • Common defenses -denial, minimization, splitting,

projective , dissociation, and guilt • Mode of object relatedness involves projection and

introjection

COGNITIVE FACTORS

• Affected persons cannot process or rationalize the trauma that precipitated the disorder.

• They continue to experience the stress and attempt to avoid experiencing it by avoidance techniques.

• Less decline in vividness, emotional intensity, and accuracy of traumatic memories.

• Exhibit difficulty retrieving specific memories • Difficulties of attentional control

Emotional Stroop paradigm

• Delayed naming of the word's colour

• Heightened stroop interference for trauma words in PTSD

Fear conditioningMowrer's two-factor conditioning theory

Traumatic stimuli (UCS) fear&arousal UCS+CS fear response stimulus

generalization variety of stimuli become triggers avoidance of CS negative reinforcement by operant conditioning prevents extinction of conditioned fear responses maintains the problem.

•

Noradrenergic System

• Nervousness, increased blood pressure and heart rate, palpitations, sweating, flushing, and tremors -symptoms of adrenergic drugs.

• Increased 24-hour urine epinephrine concentrations in veterans

• Increased urine catecholamine concentrations in sexually abused girls

• Platelet alpha2- and lymphocyte beta 2 adrenergic receptors are downregulated

• Flashbacks after yohimbine administration

HPA Axis

• Low plasma and urinary free cortisol

• CRF challenge yields a blunted ACTH response

• DMST- enhanced suppression of cortisol

• Indicates hyper-regulation of HPA axis

Structural changes

• Lower average volume in the hippocampal region

• Structural changes in the amygdale

Exaggerated Startle Responses

• Larger EMG eye blink responses to a sudden auditory stimulus

• Increased HR

NEUROIMAGING

• PET Studies-less anterior cingulate activation during the emotional Stroop task

• fMRI experiment- attenuated rostral anterior cingulate activation when exposed to war-related words

• Dysfunction in the medial prefrontal cortex and amygdala

• Hypoactive medial PFC loss of inhibition on amygdala hyper-responsive amygdala

DSM-IV-TR Diagnostic Criteria for Posttraumatic Stress Disorder

The person has been exposed to a traumatic event in which both of the following were present:

• The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

• The person's response involved intense fear, helplessness, or horror.Note: in children, this may be expressed instead by disorganized or agitated behavior

The traumatic event is persistently re-experienced in one (or more) of the following ways:

Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content.

Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in young children, trauma-specific reenactment may occur.

Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

Efforts to avoid thoughts, feelings, or conversations associated with the trauma

Efforts to avoid activities, places, or people that arouse recollections of the trauma

Inability to recall an important aspect of the trauma Markedly diminished interest or participation in significant

activities Feeling of detachment or estrangement from others Restricted range of affect (e.g., unable to have loving feelings) Sense of a foreshortened future (e.g., does not expect to have

a career, marriage, children, or a normal life span

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more)

Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response

• Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or moreSpecify if: With delayed onset: if onset of symptoms is at least 6 months after the stressor

DSM-IV

• Avoidance/numbing cluster of symptoms - requiring a minimum of three

• Increased arousal is necessary

• Minimum symptom duration of 1 month

• Significant distress or impaired functioning

ICD-10 research diagnostic criteria.

• Not included• Patient could be diagnosed

as having PTSD in the absence of hyperarousal symptoms if amnesia is present

• Not included• Not included

PTSDs in Children and Adolescents

• High rates –war related trauma, kidnapping, severe illness or burns, bone marrow transplantation, natural and man-made disasters

• Underestimated in children and adolescents.

• Family factors • Parents' responses to

traumatic events

Reenactment and Reexperiencing

• Reexperience the traumatic event in the form of distressing, intrusive thoughts or memories, flashbacks, and dreams

• Nightmares, flashbacks also play a role

• Traumatic play, a specific form of reexperiencing seen in young children, consists of repetitive acting out of the trauma or trauma-related themes in play

•

• Older children may incorporate aspects of the trauma into their lives in a process termed reenactment.

• Impulsive acting out secondary to anger, sexual acting out, substance use, and delinquency

• Regressive behaviors, such as enuresis or fear of sleeping alone

Gulf War Syndrome

• Began in 1990 and ended in 1991

• Irritability, chronic fatigue, shortness of breath, muscle and joint pain, migraine headaches,

• Digestive disturbances, rash, hair loss, forgetfulness, and difficulty concentrating .

• Amyotrophic lateral sclerosis (ALS)

11/9/01

• Terrorist activity destroyed the world trade center in new york city and damaged the pentagon in washington.

• Survey found a prevalence rate of 11.4 percent for PTSD and 9.7 percent for depression in US citizens 1 month after 11/9

Tsunami

• December 26, 2004.• Many survivors continue to

live in fear and show signs of PTSD

• Fishermen fear venturing out to sea

• Children fear playing at beaches they once enjoyed

• Trouble sleeping in fear of another tsunami

Hurricane

• In August 2005, a category 5 hurricane, Hurricane Katrina, ravaged the Gulf of Mexico, the Bahamas, South Florida, Louisiana, Mississippi, and Alabama

Earthquake

• On October 8, 2005, a 7.6 magnitude earthquake hit South Asia, affecting Pakistan, Afghanistan and Northern India.

• More than 85,000 casualties have occurred .

• Up to 3 million people were left homeless.

• Many cases of PTSD developed among those who experienced these disasters

• Recently in japan

Torture

• Defined as any deliberate infliction of severe mental pain or suffering, usually through cruel, inhuman, or degrading treatment or punishment.

• Torture is distinct from most other types of trauma because it is human inflicted and intentional.

• physical -beatings, burning of the skin, electric shock, or asphyxiation

• Psychological -threats, humiliation, or being forced to watch others, often loved ones, being tortured.

BRAIN WASH

• Combine physical and psychological aspects is brainwashing.

• Prevalence rates of PTSD among survivors of torture are about 36 percent

DIFFERENTIAL DIAGNOSIS• Organic considerations -epilepsy, alcohol-use disorders, and

other substance-related disorders, Acute intoxication or withdrawal from some substances

• Panic disorder and generalized anxiety disorder: PTSD associated with re-experiencing and avoidance of a trauma

• Borderline personality disorder, dissociative disorders, and factitious disorders.- do not usually have the degree of avoidance behavior, the autonomic hyperarousal, or the history of trauma

• Obsessive-compulsive disorder (OCD) and generalized anxiety disorder.-PTSD concerns memory—the intrusion of past stressors into the present. In contrast, OCD concerns current and future threats

Course and Prognosis

• Symptoms can fluctuate ,most intense during periods of stress.

• Untreated, about 30 percent of patients recover completely,

• 40 percent continue to have mild symptoms, • 20 percent continue to have moderate symptoms• 10 percent remain unchanged or become worse.• After 1 year, about 50 percent of patients will

recover

Good prognostic factors

• Rapid onset of the symptoms

• Short duration <6 months• Good premorbid

functioning • Strong social supports• Absence of other

psychiatric, medical, or substance-related disorders

Poor prognostic factors

• The very young • very old • Pre-existing psychiatric

disability, whether a personality disorder or a more serious condition

TREATMENT

Some principles for management

• Comorbid depression – treat PTSD first.• Substance dependence should be addressed

first before treating PTSD• Support, encouragement to discuss the event,

and education about a variety of coping mechanisms

• Sedatives and hypnotics can be helpful.

Pharmacotherapy

• SSRI’S-sertraline and paroxetine are considered first-line treatments for PTSD

• TCA’S-Imipramine and amitriptyline .Dosages same as those used to treat depressive disorders, trial should last at least 8 weeks. continue the pharmacotherapy for at least 1 year if respond well

• MAOI’S -phenelzine ,trazodone are effective in reducing re experiencing symptoms and insomnia.,

• Anticonvulsants :carbamazepine , valproate• Benzodiazepines-Benzodiazepines do not

appear to be effective although they may show some effects on insomnia, irritability, and general anxiety and arousal symptoms

CBTEducation• about the symptoms of PTSD , treatment

rationales, Common reactions to trauma ,giving up behaviours that maintain the problem such as avoidance and safety behaviours.

Self-monitoring of symptoms• self-monitoring may in itself be therapeutic

Exposure

• Imaginal exposure. • In vivo exposure - going to

the site of the traumatic event, driving again after a road traffic accident

• Exposure is repeated until the patient no longer responds with high levels of distress.

• Helps in correcting dysfunctional beliefs about danger

Cognitive therapy

• For anxiety disorder focus on identification and modification of misinterpretations that lead to overestimation of threat and under estimation of their coping abilities

• But in PTSD the perceived threat arise from the interpretation of trauma and its consequences.

• The patient is encouraged to drop behaviour and cognitive strategies that leads to negative interpretation.

Eye-movement desensitization reprocessing

• New and controversial treatment.• Patient is instructed to focus on a

trauma-related image and its accompanying feelings, sensations, and thoughts, while visually tracking the therapist's fingers as they move back and forth in front of the patient's eyes.

• After a set of approximately 24 eye movements, cognitive and emotional reactions are discussed with the therapist.

• Once the distress to traumatic image is reduced coping statements are also introduced while the scene is being imagined.

Psychodynamic therapy• The goal of the treatment is to work through and

resolve an unconscious conflict which the traumatic event is thought to have provoked.

Hypnotherapy• The goal of this treatment is to enhance control over

trauma-related emotional distress and hyperarousal symptoms and to facilitate the recollection of details of the traumatic event

• The effect is below trauma focused CBT or EMDR

• Avoidance is one of the main symptoms of PTSD, and it can thus take years for the patient to seek help for this condition

PTSD-NOT ALL WOUNDS ARE VISIBLE

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