Post Traumatic Stress Disorder

1. Post Traumatic Stress Disorder David A. Brady, D.O. Midlothian, Virginia

2. 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.

3. Anxiety Disorders There are five major types of anxiety disorders. Each has different symptoms but all symptoms cluster around excessive, irrational fear, and dread. • Generalized Anxiety Disorder • Obsessive-Compulsive Disorder • Panic Disorder • Posttraumatic Stress Disorder • Social Phobia (Social Anxiety Disorder)

4. 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%.]

5. 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.

6. 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) Traumatic Events

7. 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.

8. 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

9. 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.

10. 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%)

11. 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 status • Parental neglect • Family or personal history of psychiatric illness • Initial severity of reaction to traumatic event • Previous exposure to trauma

12. 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 engageappropriate cognitive strategies

13. 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

14. 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

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

16. Nightmares

17. Problems With Authority

18. Loss of Faith

19. Bias and Hate

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

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

22. 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.

23. Diagnosis 6 categories: • Subjective and objective components of exposure to trauma • Reexperiencing of the trauma • Persistent avoidance of the trauma • Increased arousal • Duration > 1 month • Disturbance causes social and vocational impairment…

24. DSM IV criteria

25. DSM IV Criteria

26. 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.

27. Amygdala hyperactivity combined with hippocampal atrophy seems to be consistent with diagnosis of PTSD. • TBI that has destroyed amygdala function will prevent PTSD.

28. Screening • PTSD checklist • PCL-M or the PCL-C • Clinician Administered PTSD Scale (CAPS) • SPAN (Startle, Physiological Arousal, Anger, and Numbness)

29. 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

30. 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.

31. Treatment of PTSD

32. 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

33. 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

34. 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

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

36. Grossman “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…”

37. The End