PTSD

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 DSM-IV Anxiety Disorders
• Specific phobias
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder
• Social phobia
• Obsessive-compulsive disorder
• PTSD
 PTSD: Presentation Outline
• Introduction/History
• Clinical Presentation/DSM-IV Criteria
• Differential Diagnosis
• Etiology/Risk Factors
• Treatment Issues
• Prevention
 Introduction/History
• First appeared in DSM-III (1980)
• Recognized by Shakespeare in Henry IV
• Civil War descriptions
• WWI- shell shock and soldier’s heart
• WWII- operational fatigue and combat
neurosis
• Organic origin vs psychogenic derivation
 Diagnostic Criteria for PTSD
• A. Exposed to traumatic event
– The person experienced, witnessed, or was
confronted with an event involving actual or
threatened death, serious injury or a threat to
physical integrity of self or others
– The person’s response involved intense fear,
helplessness or horror
 Diagnostic Criteria for PTSD
• B. The traumatic event is reexperienced in
one or more of the following ways
– Recurrent images, thoughts or perceptions
– Recurrent distressing dreams of the event
– Acting or feeling as if the event was recurring
– Intense psychological distress OR physiologic
reactivity at exposure to cues that symbolize or
resemble an aspect of the event
 Diagnostic Criteria for PTSD
• C. Persistent avoidance of stimuli associated with
trauma and numbing as indicated by 3 or more:
– Avoiding thoughts, feelings, or discussion, activities,
places or people that bring back recollections; sense of
foreshortened future
– Inability to recall; restricted affect
– Diminished interest or participation
– Feeling detached or estranged
 Diagnostic Criteria for PTSD
• D. Persistent symptoms of increased arousal by 2
or more:
– Difficulty falling or staying asleep
– Irritability or outbursts of anger
– Difficulty concentrating
– Hypervigilance
– Exaggerated startle response
• E. Duration for more than 1 month
 Diagnostic Criteria for PTSD

• F. Clinically significant impairment in functioning

• Acute: Less than 3 months

• Chronic: Greater than or equal to 3 months
• With delayed onset: Onset at least 6 months after
the stressor
 Diagnostic Criteria for Acute
Stress Disorder
• A: Exposed to traumatic event
• B. Experiences three or more of:
– Subjective sense of numbing, detachment
– Reduction in awareness of surroundings
– Derealization
– Depersonalization
– Dissociative amnesia
• C. Persistent reexperiencing of the event
 Diagnostic Criteria for Acute
Stress Disorder
• D. Marked avoidance of stimuli that arouse
recollections of the trauma
• E. Marked symptoms of anxiety or
increased arousal
• F. Causes significant impairment
• G. Lasts 2 days to 4 weeks and occurs
within 4 weeks of the trauma
 Epidemiology
• Prevalence of PTSD: 1-14% community, 3-
58% in at-risk populations
• 25-30% lifetime prevalence in Vietnam
veterans
• 85% in concentration camp survivors
• May be modulated by cultural differences
• All ages; individuals or groups; F>M
 Differential Diagnosis
• Mental disorder secondary to GMC
– (ex. head injury)
• Substance-induced disorder
• Dissociative disorders
• Major depressive episode
• Borderline personality disorder
• Malingering
 Etiological Factors
• Magnitude of the stress exposure
• Cognitive appraisal factors
• Intense fear or helplessness predictive
• Sympathetic hyperactivity
• Psychological factors
– psychodynamic
– cognitive
– behavioral
Examples of Traumatic Events
• Violent crime • Complicated or
• Sexual trauma unexpected
bereavements
• Chronic physical
abuse • Accidents
• Military combat • Captivity
• Natural disasters
• Manufactured
disasters
 Risk Factors
• Lack of social support • Parental poverty
• Family psychiatric • Abuse in childhood
history, esp. anxiety • Childhood behavioral
• Previous psychiatric problems
history • Limited education
• Certain personality • Adverse life-events
traits prior to trauma
• Early separation of • Female
parents
 Six Strongest Predictors of
Trauma Exposure
• Male
• Absence of college education
• Extroversion
• Neuroticism
• Early misconduct
• Family psychiatric illness
 Six Strongest Predictors
for Risk of PTSD
• Female
• Neuroticism
• Early separation from parents
• Prior anxiety or depression
• Familial anxiety
• Familial antisocial personality disorder
Associated Symptoms Important
for Treatment
• Survival and behavioral guilt
• Somatic distress
• Paranoia
• Interpersonal alienation
• Vegetative changes of depression
• Hopelessness
• Impulsivity
 Course and Prognosis
• 30% recover completely
• 40% continue with mild symptoms
• 20% moderate symptoms
• 10% unchanged or worsen
• Startle, nightmares, irritability and
depression often worsen with age
• Comorbidity is high (MDD, OCD, Panic,
substance abuse)
 Treatment: ASD
• Talking about the trauma allowing:
– confrontation
– acceptance
– process
– integration
• Individual or group therapy, hypnosis
• Followed by support and superficiality
 Treatment: PTSD
• Requires multiple modalities
• Initial education, support and referrals
important to establish trust
• Pharmacotherapy
• Psychotherapy
• Relaxation Training
 Treatment: PTSD-
Pharmacotherapy
• Duration of at least 8-12 weeks
• Adequate dosages
• Maintenance treatment for at least 1 year
• Antidepressants
• Mood stabilizers
• Propranolol, clonidine
• Atypical antipsychotics
 Drug Treatment of PTSD
• Amitriptyline • 50-300 mg/day
• Fluoxetine • 20-60
• Sertraline* • 50-200
• Paroxetine* • 20-50
• Propranolol • 40-160
• Clonidine • 0.2-0.6
• Valproic Acid • 750-1,750
• Carbamazepine • 200-1,200
 Drug Treatment of PTSD
• Lithium • 300-1,500 mg/day
• Quetiapine • 25-700
• Risperidone • 0.5-6
• Olanzapine • 2.5-20
 Treatment: PTSD-
Individual Psychotherapy
• Crisis Intervention
– establish rapport, promote acceptance
– educate, attend to general health
• Trauma-focused psychotherapy
• Implosive therapy
• Systematic desensitization
• Hospitalization may be necessary at times
 Points to Remember
• If a patient has multiple complaints, think
PTSD or personality disorder up front
• Under-detected because we don’t ask the
right questions
• One of the few DSM disorders defined by
it’s cause!
 DREAMS
Detachment
Re-experiencing the event
Emotional effects
Avoidance
Month in Duration
Sympathetic hyperactivity or hypervigilance
PTSD Questionnaire