Epidemiology, Etiology, & Treatment What is PTSD? Anxiety

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Posttraumatic Stress Disorder (PTSD)

• Epidemiology, Etiology, Treatment

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What is PTSD?

• Anxiety disorder
• Traumatic stressor
• Core features
• Reexperiencing
• Avoidance
• Numbing
• hyperarousal

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Traumatic Stressor

• DSM-III Beyond normal range of human experience

• DSM-IV experiences, witnesses, or is exposed to
  an event that is life threatening, that causes
  serious injury or that leads to a subjective
  response of intense fear, helplessness, or horror.

• PTSD is unique among mental disorders
• Symptoms are directly linked to traumatic
  stressor

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Historical Overview Diagnostic category in
DSM-III
Issues Symptoms alone Social
Construction Unreliability of memory
Euro-American category
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But

• Traumatic neurosis (Oppenheim in 1892)
• Fright neurosis or schreckneurose (Kraeplin in
  1896)
• WWs I II
• Shell shock
• Combat fatigue
• War neurosis
• DSM-I GSR
• DSM-II Transient situational disturbances

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Epidemiology

• Four levels
• Prevalence of Trauma Exposure
• Risk Factors for Trauma Exposure
• Prevalence of PTSD
• Risk and Protective Factors

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Prevalence of Trauma Exposure

• Common or uncommon?
• NCS 60.7 of men 51.2 have had at least 1
  traumatic event in their lifetime
• Most common traumatic events
• Witnessing
• Natural disasters
• Life-threatening accidents
• Rape
• Sexual molestation
• Physical abuse
• Childhood neglect

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Risk Factors For Trauma Exposure

• Random or non-random?
• Gender
• Age
• Prior exposure
• Preexisting personal characteristics
• CDD
• Pretrauma substance use
• Genetic Vulnerability

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Prevalence of PTSD

• Several factors
• PTSD ratio of women to men is
• 21 in USA
• Different among VTV
• Higher for men
• Roles, stressors, education levels
• Demographics
• Age
• Ethnicity
• Population
• Gender
• Trauma type 32 of rape 26 of criminal
  victims
• Closeness to Traumatic event - WTC

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Prevalence of PTSD

• International data varies
• Economies and PTSD
• Political turmoil, wars, disasters
• PTSD manifests itself in similar manner across
  culture, language, region, race
• Importance of this observation?

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Risk and Protective Factors

• Many are exposed but few develop PTSD
• Ratio of 31
• Categories of Risk Factors
• Trauma
• Peri-and post-trauma events
• Individual Characteristics

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Risk and Protective Factors

• Trauma
• Type
• severity
• Peritrauma
• Fear, helplessness, horror (r .26)
• Dissociation blanking out, altered sense of time
• PTSD is exercerbated by cognitions of panic (fear
  of death, fear of losing control)
• Posttrauma
• Social support
• PTSD SS vs SS PTSD

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Individual Characteristics Demographics
Familial Psychopathology

• Demographics
• age, gender, race, SES, immediate response,
  marital status, psychiatric history, prior
  trauma, personality
• Familial Psychopathology
• VVTR (no genetic linkage)
• In general population (small but sig.) through
  D2 dopamine alleles
• Environment
• (greater than genetics)

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Predictor Effect

• Direct
• War-zone stressors, malevolent war-zone
  environment
• Hardiness, structural social support (not sig.
  for w/men), functional social support, and recent
  stressors
• Indirect
• Traditional combat exposure moderated by
  perceived threat

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Etiological Theories

• Multiple Theories
• Classical Conditioning
• stimulus response connection
• Schema Theories
• faulty schemas that filter info
• Emotional Processing Theory
• - abnormal fear structures
• Cognitive Theory
• - (i) classical (ii) Ehler Clark
• Multiple Representation Structures
• (i) Dual VAM SAM
• (ii) SPAARS schematic, proporsitional,
  analogue, associative
  representational systems

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Classical Conditioning
Triple vulnerability
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Concern about CC

• Startle responses
• Reexperiencing
• Nightmares

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Treatment

• Approaches
• (influenced by Psychoanalysis)
• Exposure Therapies
• Narrative therapies
• CT
• CPT
• PE
• IR (imagery rescripting)
• IRT (imagery rehearsal therapy)
• Concerns?
• Anxiety Management Training
• Stress innoculation techniques

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Treatment

• Combination Treatments
• EAMT CR eg CPT
• CBT
• TF-CBT
• DBT
• Power Therapies TIR, VK/D, EMDR (concern?)
• ACT
• Interapy
• VRE
• Pharmacotherapy

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Pharmacotherapy
Challenge multiple rather than single
neurobiological systems
Assumption

• Target Systems
• Adrenergic
• HPA
• Serotonergic
• Dopaminergic

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Medication

• Antidepressants
• SSRI sertraline, paroxetine, fluoxetine
• TCA amitriptyline, desipramine
• MAOI - phenelzine
• Antiadrenergic
• prozasin
• Antikindling
• Carbamazepine
• Atypical antipsychotic
• resperidone, quetiapine, olanzapine

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Research

• Efficacious in comparison to WL
• Decline in anxiety, arousal, reliving
• Narrative therapy cf psychoeducation
• Exposure (alone)
• Active therapies vs supportive therapies
• PE (60-80, Foa, Rothbaum, Faurr, 2003)
• IRT 65 (Jacobson Traux, 1991)
• VRE 15-67 (Rothbaum et al. 1999)

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Limitation

• Cultural issues

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Resources

• Friedman, M., Keane, T, Resick, P. (Eds.)
  (2007). Handbook of PTSD Science and
  practice. New York The Guilford Press.
• Keane, T., Marshall, A., Taft, C. (2006).
  Posttraumatic stress disorder Etiology,
  epidemiology, and treatment outcome. Annual
  Review Clinical Psychology, Vol. 2, 161-197.
• Vasterling, J., Brewin, C. (Eds.) (2005).
  Neuropsychology of PTSD Biological, cognitive,
  and clinical perspectives. New York The
  Guilford Press.