Post Traumatic Stress Disorder

David A. Brady, D.O.

Midlothian, Virginia

Anxiety

Anxiety is a normal reaction to stress. It helps us deal with stressful situations, makes us more aware, increases focus and concentration.

Anxiety becomes a problem when it becomes an excessive, irrational dread of a situation, event, or object.

Anxiety Disorders

There are five major types of anxiety disorders. Each has different symptoms but all symptoms cluster around excessive, irrational fear, and dread.

1. Generalized Anxiety Disorder2. Obsessive-Compulsive Disorder3. Panic Disorder4. Posttraumatic Stress Disorder5. Social Phobia (Social Anxiety Disorder)

Relevance

Lifetime prevalence of PTSD is 1% - 15% in the U.S. population.

[In high-risk groups, such as combat veterans and victims of violent crimes, prevalence ranges from 3% to 58%.]

Relevance

PTSD is more prevalent among war veterans than among any other group.

The National Vietnam Veterans Readjustment Survey reports that approximately 25% of U.S. veterans, men and women, were suffering from PTSD in the early 1990s.

Traumatic Events War Mugging Rape Torture Kidnapping Held captive Child abuse Accidents (work

related, MVA)

Acts of terror Train wrecks Ship wrecks Air plane crashes Bombings Natural disasters Medical Procedures

(Surgeries, ICU / CCU Stays, Chemotherapy, Burn Treatments)

Posttraumatic Stress Disorder “The complex somatic, cognitive, affective

and behavioral effects of psychological trauma.”

It is characterized by intrusive thoughts, nightmares and flashbacks of past traumatic events, avoidance of reminders, hypervigilance, and sleep disturbance, which lead to social, occupational and interpersonal dysfunction.

Posttraumatic Stress Disorder

“Neurobiological research has helped us to understand that PTSD is not an “emotional” or “psychological” disorder, but a physiological condition that effects the entire body, including cardiovascular functioning, hormone system balance, and immune functioning.”

Hoge

Posttraumatic Stress Disorder

Many people exposed to trauma will experience distress with similar symptoms associated with PTSD.

PTSD is a subset of people who are significantly impaired of a period of time greater than 1 month.

Epidemiology Lifetime prevalence 6.8-12.3 percent Estimated 11 to 17 percent of US veterans

returning from active duty in Afghanistan and Iraq Onset at any age Females > males (4X more likely to develop sx) Susceptibility may run in families Associated with drug and alcohol abuse and/or

dependence Look for one or more of the other anxiety disorders PTSD is associated with increased median annual

health care costs (38 to 104%)

Epidemiology Risk factors

Lack of social support = dissociation associated with the trauma

Extent of injury is strongly correlated with PTSD (those in combat)

Lower socioeconomic statusParental neglectFamily or personal history of psychiatric illnessInitial severity of reaction to traumatic eventPrevious exposure to trauma

Pathophysiology Unclear pathophysiology MRI studies have shown decreased hippocampal volume in

patients with PTSD. Increased central norepinephrine levels with down-regulated

central adrenergic receptors, chronically decreased glucocorticoid levels with up regulation of receptors.

Hemispheric lateralization Abnormalities in amygdala

exaggerated response of the amygdala, resulting in impaired regulation by the medial prefrontal cortex

patients with PTSD have diminished activation of the medial prefrontal cortex during the processing of fear

Insufficient cognitive resources to engage appropriate cognitive strategies

Clinical Presentation Marked cognitive, affective, and behavior

responses to stimuli, leading to flashbacks, severe anxiety and fleeing or combative behavior.

Individuals compensate by avoiding triggers and generally shutting down.

Emotional numbing and diminished interest in everyday activities with detachment from others.

Sense of a foreshortened future Psychiatric comorbidity is high:

Depression, anxiety, substance abuse, and somatization disorders

Anger / Irritability “Anger is an emotion, an immediate

internal reaction to a situation.” “A problem in our society, and in the

approach to anger “management”, is that anger - the emotion - is often confused with other responses.”

“It is not the anger that needs managing, but the various behaviors that can arise from it.”

Hoge

Flashbacks

Flashbacks consist of images, sounds, smells, or feelings triggered by ordinary events (Examples: car backfires, door slams).

Nightmares

Problems With Authority

Loss of Faith

Bias and Hate

Symptoms

“Every “symptom” included in the definition can also reflect normal responses to life-threatening events or the normal way the body responses to extreme stress.”

Hoge

Symptoms

Symptoms are usually worse if the traumatic event was triggered by another person (examples: rape, terror, mugging, direct contact in war).

Mental Status Exam General appearance may be affected (disheveled / poor personal

hygiene). Behavior may be altered. Agitated, extreme startle reaction. Orientation is sometimes affected. The patient may not know the

current place or time. Patients may report forgetfulness, especially concerning the

specific details of the traumatic event. Concentration is poor. Impulse control is poor. Speech rate and flow may be altered. Mood and affect may be changed. Patients may have feelings of

depression, anxiety, guilt, and/or fear. Patients may be more concerned with the content of

hallucinations, delusions, suicidal ideation, phobias, and reliving the experience. Certain patients may become homicidal.

Diagnosis6 categories:1. Subjective and objective components of

exposure to trauma2. Reexperiencing of the trauma3. Persistent avoidance of the trauma4. Increased arousal 5. Duration > 1 month6. Disturbance causes social and

vocational impairment…

DSM IV criteriaA.A. The person has been exposed to a traumatic event in which both The person has been exposed to a traumatic event in which both

of the following have been present: of the following have been present: (1)(1) the person experienced, witnessed, or was confronted with an event or events that 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 involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others integrity of self or others

(2)(2) the person's response involved intense fear, helplessness, or horror. the person's response involved intense fear, helplessness, or horror. Note:Note: In In children, this may be expressed instead by disorganized or agitated behavior. children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) B. The traumatic event is persistently reexperienced in one (or more) of the following ways: of the following ways: 

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

(2)(2) recurrent distressing dreams of the event. recurrent distressing dreams of the event. Note:Note: In children, there may be In children, there may be frightening dreams without recognizable content. frightening dreams without recognizable content.

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

(4)(4) intense psychological distress at exposure to internal or external cues that symbolize intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.or resemble an aspect of the traumatic event.

(5)(5) physiological reactivity on exposure to internal or external cues that symbolize or physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. resemble an aspect of the traumatic event.

DSM IV CriteriaC. Persistent avoidance of stimuli associated with the trauma and C. Persistent avoidance of stimuli associated with the trauma and

numbing of general responsiveness (not present before the numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following: trauma), as indicated by 3 or more of the following: 

(1)(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid thoughts, feelings, or conversations associated with the trauma (2)(2) efforts to avoid activities, places, or people that arouse recollections of the efforts to avoid activities, places, or people that arouse recollections of the

trauma trauma (3)(3) inability to recall an important aspect of the trauma inability to recall an important aspect of the trauma (4)(4) markedly diminished interest or participation in significant activities markedly diminished interest or participation in significant activities (5)(5) feeling of detachment or estrangement from others feeling of detachment or estrangement from others (6)(6) restricted range of affect (e.g., unable to have loving feelings) restricted range of affect (e.g., unable to have loving feelings) (7)(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, sense of a foreshortened future (e.g., does not expect to have a career, marriage,

children, or a normal life span)children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 or more of the following: indicated by 2 or more of the following: (1) difficulty falling or staying asleep (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (2) irritability or outbursts of anger (3) difficulty concentrating (3) difficulty concentrating (4) hypervigilance (4) hypervigilance (5) exaggerated startle response(5) exaggerated startle response

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

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

Imaging in PTSD

MRI studies of the brain suggest that the amount of hippocampal atrophy correlates with the intensity of PTSD symptoms, but MRI is still not a recommended diagnostic test. Some studies in monozygotic twins show that a small hippocampus may be a predisposing factor to the later development of PTSD in the face of a stressor.

Amygdala hyperactivity combined with hippocampal atrophy seems to be consistent with diagnosis of PTSD.

TBI that has destroyed amygdala function will prevent PTSD.

Screening PTSD checklist

PCL-M or the PCL-C

Clinician Administered PTSD Scale (CAPS)

SPAN (Startle, Physiological Arousal, Anger, and Numbness)

Differential Diagnosis

Acute stress disorder

Traumatic Brain Injury

Adjustment disorder

Malingering (must be excluded)

Mood disorder with or without psychotic features

Psychotic disorders caused by a general medical condition

Substance induced disorders

Implications in Primary Care The diagnosis of PTSD can be missed in a

primary care setting, as patients frequently present with somatic complaints or depression and are often reluctant to discuss their traumatic experiences.

Treatment of PTSD

Treatment of PTSD Treatment is often best accomplished with a combination of

pharmacologic and nonpharmacologic therapies.

Medications may be required to control the physiological symptoms, which can enable the patient to tolerate and work through the highly emotional material in psychotherapy.

SSRI’s are first choice in medical management

Prazosin for nightmares

Atypical antipsychotics

If present, alcohol or substance abuse problems should be the initial focus of treatment

Hyperarousal symptoms can be treated with B-blockers

Treatment of PTSD Exposure Therapy Group Therapy Support Groups Don’t insult the patient Never tell the patient: Don’t talk about your

trauma, talk about your feelings… Virtual Reality Sexual Issues (psychological and

physiological) Physical Issues

Treatment of PTSD Don’t forget the forgotten (spouses, children,

mothers, fathers, brothers, sisters, friends, neighbors, ministers, healthcare providers…)

Close medical follow-up Exercise Recreation Routine (Sleep) Vocational Rehabilitation Education Spiritual Issues

Prognosis

PTSD is a chronic condition with 1/3 of patients recovering at one year and 1/3 symptomatic at 10 years…

“I hold it to be a fundamental truth of human nature, that when someone withholds something traumatic it can cause great damage. When you share something with someone it helps to place it in perspective, but when you hold it inside, as one of my students once put it, “it eats you alive from the inside out.” Furthermore, there is great therapeutic valve in the catharsis that comes with lancing these emotional boils. The essence of counseling is that pain shared is pain divided…”

Grossman

The End