Diagnosis

1
PTSD POST TRAUMATIC STRESS DISORDER

• Diagnosis
• Treatment

2
Prevalence General Population NCS

• Lifetime PTSD prevalence 6.8
• 10 women
• 5 men

3
Examples of Traumatic Events

• Violent Crime
• Sexual Trauma
• Chronic Physical Abuse
• Military Combat
• Natural Disasters
• Manufactured Disasters
• Complicated or Unexpected Bereavements
• Accidents
• Captivity

4
Government Statistics

• PTSD Lifetime Prevalence among 3000 Vietnam
  Veterans

• Prevalence of PTSD among Vietnam Veterans by
  Race/Ethnicity Subgroups

• 31 men
• 26 women

• 27 Hispanic
• 25 American Indian Northern Plains
• 22 American Indian Southwest
• 21 African American
• 14 Caucasian
• 12 Native Hawaiian
• 2 Americans of Japanese Ancestry

5
PTSD and Recent Wars

• Gulf War
• prevalence 10
• Afghanistan
• prevalence 6-11.5

• Iraq
• Army prevalence 13-18
• Marine prevalence 12-20

6
Male Female Differences

• Prevalence of trauma exposure higher in men
• Male 61
• Female 51
• Women exposed to trauma have 2 X gt chance of PTSD
  
• Male 8.2 (most common trauma combat)
• Female 20.4
• Lifetime prevalence of PTSD 2 xgt among women than
  men
• Males 5.0 (most common trauma combat)
• Females 10.4 (most common trauma rape)

7
DSM-IV Diagnostic Criteria

• Symptoms are organized in clusters
• Exposure to traumatic stressor
• Re-experiencing symptoms
• Avoidant/numbing symptoms
• Hyperarousal symptoms
• The duration of symptoms criteria
• Impairment criteria

8
Cluster A EXPOSURE

• Exposure to a traumatic event in which the
  person
• Experienced, witnessed, or was confronted by
  death or serious injury to self or others
• and
• Responded with intense fear, helplessness, or
  horror

9
Cluster B RE-EXPERIENCING

• Persistent re-experiencing of gt 1 of the
  following
• Recurrent distressing recollections of event
• Recurrent distressing dreams of event
• Acting or feeling event was recurring
• Psychological distress at cues resembling event
• Physiological reactivity to cues resembling event

10
Cluster C AVOIDANT/NUMBING CRITERION

• Avoidance of stimuli and numbing of general
  responsiveness gt 3
• Thoughts, feelings, or conversations
• Activities, places, or people
• Inability to recall part of trauma
• Decreased interest in activities
• Estrangement from others
• Restricted range of affect
• Sense of foreshortened future
• Related to the trauma

11
Cluster "DHYPERAROUSAL CRITERION

• Persistent symptoms of increased arousal gt 2
• Sleep difficulties
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

12
Cluster E DURATION CRITERIA

• 30 days

13
Cluster F IMPAIRMENT CRITERIA

• Symptoms cause clinically significant distress
  or impairment in functioning

14
Specifiers

• Acute
• Less than 3 months
• Chronic
• 3 months or longer
• With delayed onset
• If onset of symptoms at least 6 months or later
  after trauma

15
Risk Factors

• Pretraumatic
• Peritraumatic
• Posttraumatic

16
Risk Factors Pretraumatic

• Female gender
• Adverse childhood experiences
• Genetic vulnerability to psychiatric illness
• Poor social support
• Concurrent stressful life events
• Prior psychiatric illness
• Borderline, Paranoid, Dependent, or Antisocial
  Personality Disorder or traits

17
Risk Factors Peritraumatic

• A dose response curve
• The greater the
• Severity of the exposure to the traumatic event
• Degree of helplessness, fear, horror
• Unpredictability of the stressor
• The greater the likelihood of developing PTSD

18
Dose Response Curve Illustration

• Incidence of PTSD related to the number of combat
  exposures
• No. of Events Incidence
• 0 4.5
• 1-2 9.3
• 3-5 13
• 5 19
• NEJM. 200435113-22

19
Risk Factors Posttraumatic

• Most important
• Social support following the event
• Timing of treatment
• Continual exposure

20
PTSD Comorbidity

• Depression and other mood disorders
• Dissociative disorders
• Other anxiety disorders
• Alcohol and other substance use disorders
• Psychotic features or psychotic disorders
• Personality disorders

21
Differential Diagnosis of PTSD

• If a patient has multiple complaints, think PTSD
  or personality disorder up front
• Under-detected because we dont ask the right
  questions
• PTSD is one of the few DSM disorders defined by
  its cause

22
Differential Diagnosis

• Adjustment Disorder
• Psychotic Disorders (flashbacks, illusions,
  hallucinations)
• Substance-related disorders (intoxication/withdraw
  al)
• Obsessive-Compulsive Disorder (recurrent
  intrusive thoughts unrelated to trauma)
• Factitious Disorder
• Malingering (if financial remuneration, benefit
  eligibility)
• Head injury
• Acute Stress Disorder (if time-limited within
  4-week period)

23
ASD Vs. PTSD

• Duration
• Symptoms present from 2 days to 4 weeks
• Resolve within 4 weeks

24
DMS-IV Diagnostic Criteria for ASD

• Same PTSD criterion A trauma exposure and
  response
• 3 or more dissociative symptoms
• 1 or more re-experiencing symptoms
• Avoidance
• Anxiety or increased arousal
• 2 days to 4 weeks from event

25
ASD Epidemiology Course

• Epidemiology
• 14-33 prevalence in severe trauma
• Course
• Symptoms start during or right after trauma
• Resolve within 4 weeks or diagnosis is changed to
  PTSD
• Conversion to PTSD 78 of MVA victims with ASD
  developed PTSD in 6 months
• Predisposing Risk Factors
• Severity and proximity to the trauma
• Previous trauma, pre-existing mental disorder,
  poor social supports

26
Acute Stress Disorder

• Early Management
• Interventions implemented immediately after a
  trauma are most successful
• Attenuates the acute response to trauma
• Averts the development of PTSD

27
PTSD Treatment

• Requires multiple modalities
• Initial education, support and referrals
  important to establish trust
• Pharmacotherapy
• Psychotherapy
• Relaxation Training

28
Pharmacological Evolution for PTSD

• 1900 Barbituates
• 1950 Meprobemate, Benzodiazapines
• 1960-80 Tricyclics and MAOI
• 1980-90 Setraline Paroxetine
• Only FDA approved for PTSD

29
PTSD Pharmacotherapy Recommendations

• Duration of at least 8-12 weeks
• Start low to minimize anxiety
• Reach adequate dosages
• Maintenance treatment for at least one year

30
PTSD Medication Treatment

• First-Line Pharmacotherapy
• SSRIs
• In particular Paroxetine (Paxil) and Sertraline
  (Zoloft) both FDA-approved and shown to reduce
  symptoms from all PTSD symptom clusters
• Treatment-Refractory Adjunctive Agents
• Second antidepressants
• MAOIs - Phenelzine
• TCAs Imipramine, Amitryptyline
• Other antidepressants Venlafaxine, Trazadone,
  Nefazodone, Mirtazapine
• Anticonvulsants - Valproic acid, Carbamazepine,
  Topiramate, Lamotrigine, Gabapentin

31
PTSD Medication Treatment (contd.)

• Antiadrenergics - Propranolol, clonidine,
  prazosin
• Buspirone
• Atypical antipsychotics Olanzapine,
  Risperidone, Quetiapine, Aripiprazole

32
PTSD Medication Treatment

• Amitriptyline 50-300 mg/day
• Nortriptyline 75-150 mg/day
• Fluoxetine 5-80 mg/day
• Sertraline 25-200 mg/day
• Paroxetine 10-50 mg/day
• Citalopram 20-40 mg/day
• Escitalopram 10-40 mg/day
• Duloxetine 20-120 mg/day
• Venlafaxine-XR 37.5-225 mg/day

33
PTSD Medication Treatment (Contd)

• Propranolol 40-160 mg/day
• Clonidine 0.2-0.6 mg/day
• Valproic Acid 750-1,750 mg/day
• Carbamazepine 200-1,200 mg/day
• Lithium 300-1,500 mg/day
• Lamotrigine 25-500 mg/day
• Quetiapine 25-400 mg/day
• Risperidone 0.5-6 mg/day
• Olanzapine 2.5-20 mg/day

34
Recommended PTSD Psychotherapies

• CBT
• Exposure Therapy
• Imagery Rehearsal Therapy
• Stress Inoculation Training
• Treatment for co-occurring presented by Dr.
  Davis
• Seeking Safety
• Transcend
• Substance Dependence PTSD therapy
• Brief Therapies by Ron Klein
• Hypnosis based Techniques VK dissociation
• EMDR (eye movement desensitization reprocessing)
• Neurolinguistic Programming Submodalities
• Integrated Approach
• Traumatic Stress Recovery Model

35
Course and Prognosis

• Longitudinal research has shown that PTSD can
  become a chronic psychiatric disorder that can
  persist for decades or a lifetime.
• Usually develops in as little as one week or, as
  part of a delayed variant, individuals exposed to
  a traumatic event do not exhibit the PTSD
  syndrome until months or even up to 30 years
  afterwards.
• Longitudinal course marked by remissions and
  relapses.
• Usually, the immediate precipitant is a situation
  that resembles the original trauma in a
  significant way.

36
Course and Prognosis (contd.)

• Symptoms may reoccur months or years later in
  response to subsequent stressful or life-changing
  events
• The very young and very old have more
  difficulties with traumatic events than do those
  in midlife.
• Favorable prognosis
• Rapid onset of symptoms
• Short duration of symptoms (6 months)
• Good premorbid functioning
• Strong social supports
• Absence of psychiatric, medical, or
  substance-related disorders