POST TRAUMATIC STRESS DISORDER: Lest We Forget

1
POST TRAUMATIC STRESS DISORDER Lest We Forget
McMaster Mini Med School March 24, 2009 Jon
Davine, MD, CCFP, FRCP(C) Associate Professor,
McMaster University
2
(No Transcript)
3
(No Transcript)
4
PTSD

• Invented 1980 in DSM
• Started with Vietnam war vets
• Quintesential environmental disease, as must have
  environmental stress

5
POST TRAUMATIC STRESS DISORDER (PTSD)

• The person has been exposed to a traumatic event
  in which both of the following were present
• 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 integrity of self or
  others
• the persons response involved intense fear,
  helplessness, or horror.

6
POST TRAUMATICSTRESS DISORDER RE-EXPERIENCING

• The traumatic event is persistently reexperienced
  in one or more of the following ways
• recurrent and intrusive distressing recollections
  of the event, including images, thoughts or
  perceptions (recurring thoughts).
• recurrent distressing dreams of the event
  (nightmares).
• acting or feeling as if the traumatic event were
  recurring (includes a sense of reliving the
  experience, illusions (flashbacks).

7
POST TRAUMATICSTRESS DISORDER - TRIGGERS

• Intense psychological distress at exposure to
  cues that symbolize or resemble an aspect of the
  traumatic event.
• Physiological reactivity on exposure to cues that
  symbolize or resemble as aspect of the traumatic
  event.
• Can become a panic attack.
• e.g., very upset if hears the squeal of brakes.

8
POST TRAUMATICSTRESS DISORDER - AVOIDANCE

• Persistent avoidance of stimuli associated with
  the trauma
• Efforts to avoid thoughts, feelings or
  conversations associated with the trauma
• Efforts to avoid activities, places or people
  that arouse recollections of the trauma
• Inability to recall an important aspect of the
  trauma
• e.g., avoid driving

9
POST TRAUMATIC STRESS DISORDER - AROUSAL

• Persistent symptoms of increased arousal (not
  present before the trauma), as indicated by two
  (or more) of the following
• difficulty falling or staying asleep
• irritability or outbursts of anger
• difficulty concentrating
• hypervigilance
• exaggerated startle response

10
POST TRAUMATICSTRESS DISORDER

• duration of the disturbance is more than one
  month
• the disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.

11

• TRAUMATIC EVENT
• RE-EXPERIENCE
• AVOIDANCE/NUMBING
• UNABLE TO FUNCTION
• MONTH
• AROUSAL (HYPERAROUSAL)

12
POST TRAUMATICSTRESS DISORDER

• Specify if
• Acute if duration of symptoms is less than
  three months
• Chronic if duration of symptoms is three months
  or more
• Specify if
• with delayed onset if onset of symptoms is at
  least six months after the stressor.
• Can happen with sexual abuse.

13
PTSD Subtype Specifiers
Chronic PTSD (gt 3 months)
PTSD Symptoms
Acute Stress Disorder
Acute PTSD (lt 3 months)
Delayed Onset PTSD
1
3
6
Time from Trauma (months)
14
SCREENING QUESTIONS

• Thus, in screening for PTSD, ask
• Do you keep re-experiencing the event?
  Nightmares
• Flashbacks (daymares)
• Can be like hallucinations
• Cant stop thinking about it.
• Can look like obsession
• Do things that remind you of the event bring out
  a huge response?
• Can look like panic attacks

15
SCREENING QUESTIONS

• Do you avoid things that remind you of the event?
• Are you personally more anxious since the event?
• ?decreased sleep, concentration
• more irritable
• startle easily
• Has it gotten in the way of your life?

16
Psychiatric Comorbidity (lifetime)
Panic9.9
Alcohol Abuse / Dependence39.9
Major Depression48.2
PTSD
GAD15.9
Social Phobia29.9
Agoraphobia19.25
Kessler et al, Arch Gen Psychiatry 1995
17
LIFETIME PREVALENCE OF PTSD APPROXIMATELY 10

• Breslan et al 91
• 9.2
• National Comorbidity Survey 91 (NCS)
• 8.7
• 5-6 males
• 10-14 females
• Detroit Area Survey of Trauma 96
• 14
• 10 males
• 18 females

18
EXPOSURE TO TRAUMATIC EVENTS

• Lifetime exposure to traumatic events
• 40-69. Only 10 get PTSD
• Higher in males/females
• 1.2 1

19
EXPOSURE TO TRAUMA

• Trauma type NCS
• Male Female
• Rape 0.7 9.2
• Sexual Assault 2.8 12.3
• Combat 6.4 0.0
• Witnessing Violence 35.6 14.5
• Accidents 25.0 13.8
• Car Accidents 32.8 23.5
• Threatened with a weapon 19.0 6.8
• Physical attack 11.1 6.9
• Natural Disaster 18.9 15.2
• Learning about trauma to others 63.1 61.8
• Sudden unexpected death 61.1 59.0

20
TRAUMA

• Extended from war, earthquakes, assaults
• MVAs grief workplace incidents
• Legitimate cause for disability

21
CONDITIONAL RISK OF PTSD

• 9 all trauma
• Females gt males 21 (adjusted for trauma type)

22
CONDITIONAL RISK FOR PTSD

• Trauma Type PTSD
• Assaultive violence 20.9
• Raped 49.0
• Shot or stabbed 15.4
• Badly beaten up 31.9
• Serious car accident 6.1
• Learning about trauma
• to others 0.2
• Sudden unexpected death
• of a close friend or relative 14.3
• Any trauma 9.2

23
CONDITIONAL RISK FOR PTSD

• Females Males
• Molestation 26.5 vs 12.2
• Threatened with
• a weapon 32.6 vs 1.9
• Assaultive Violence 35.7 vs 6.0

24
Risk Factors for PTSD Development
Peri- Trauma
Post- Trauma
Pre- Trauma
PTSD
25
Pre-Trauma Risk Factors

• Female gender
• Previous trauma / younger age at time of trauma
• Childhood abuse
• Trait neuroticism / poor coping style

Brewin et al, J Consult Clin Psychol 2000
26
Peri-Traumatic Risk Factors Influencing PTSD

• Nature of trauma (personal assault)
• Severity of trauma / chronicity of trauma

Brewin et al, J Consult Clin Psychol 2000
27
Post-Trauma Risk Factors

• Lack of social support
• Lack of appropriate early treatment or access to
  services

Yehuda et al, Biol Psychiatry1998
28
LONGITUDINAL COURSE

• 53 recovered at three months.
• 58 recovered at nine months.
• 15-25 unrecovered after years. I often see this
  with people from war zones.

29
Longitudinal Course of PTSD Symptoms
6 recovered
53 recovered
58 recovered
15-25
UNRECOVERED
3 months
9 months
Weeks
YEARS
Shalev Yehuda, Psychological Trauma 1998
30
NEUROBIOLOGY

• Studies have shown decreased size of the
  hippocampus in brain studies.
• Seat of Memory
• Different pathways
• Sabretooth Tiger example re evolutionary
  advantage, but now..

31
PTSD Treatment Options
32
CONTROVERSY

• must you re-explore the trauma --NO
• when is the most appropriate timing--WHEN THE
  PATIENT IS READY

33
CBT - Psychoeducation/Supportive Counselling

• Normal to be upset and have symptoms
• PTSD symptoms does not mean going crazy
• provide client with corrective information
  (psychoeducation)
• Its very common (10)
• Treatment can help

34
CBT-Imaginal Exposure, a Behavioural Treatment

• This is healing. It gets rid of the power of the
  event
• Literally, talking about the very thing youd
  rather not talk about
• This is the hallmark of therapy

35
CBT- In-Vivo Exposure Therapy

• Behavioural homeworks involve exposure to avoided
  activities
• Usually done as hierarchy
• Can pair it with muscle relaxation
• Must stay in the activity until calm. Dont stop
  activity while still anxious
• E.g. driving a car after an accident

36
COGNITIVE THERAPY

• Challenge automatic thoughts with evidence for
  and against
• Re-formulate to more realistic ones
• e.g. all men will assault me
• e.g. I will always have an accident

37
CAUTION!!

• I tell people talking about the difficult event
  is healing..as long as they feel ready to do it
• If they feel its too much, I say wait until you
  feel ready, and then well do it

38
ANXIETY MANAGEMENT TRAINING

• Give client skills to handle anxiety
• e.g. relaxation training, deep muscle
• breathing retraining

39
Recommendation for Pharmacotherapy for PTSD

• First-line
• Fluoxetine, paroxetine, sertraline, venlafaxine
  XR, (SSRIs, NSRI)
• Second-line
• Fluoxamine, mirtazapine, moclobemide, phenelzine
• Adjunctive resperidone, olanzapine

40
EXAMPLE SEXUAL ABUSE

• ask regarding nightmares, flashbacks, avoidance,
  triggers, mood
• not your fault, metaphorically bound and
  gagged
• if theres anything I ask you that you would
  rather not answer, you dont ...
• support. Validate feelings e.g. anger, hatred
• normalize issue of self esteem, trust, intimacy,
  sexuality
• pressure cooker analogy

41
(No Transcript)