Transcript PTSD - Terri L. Weaver, Ph.D.

Epidemiology, Etiology, & Treatment
What is PTSD?
•Anxiety disorder
•Traumatic stressor
•Core features:
•Reexperiencing
•Avoidance
•Numbing
•hyperarousal
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
Historical Overview
Diagnostic category in DSM-III
Issues
Symptoms alone
Social Construction
Unreliability of memory
Euro-American category
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
Epidemiology
Four levels
•Prevalence of Trauma Exposure
•Risk Factors for Trauma Exposure
•Prevalence of PTSD
•Risk and Protective Factors
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
Risk Factors For Trauma Exposure
Random or non-random?
•Gender
•Age
•Prior exposure
•Preexisting personal characteristics
•CDD
•Pretrauma substance use
•Genetic Vulnerability
Prevalence of PTSD
Several factors
•PTSD ratio of women to men is
2:1 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
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?
Risk and Protective Factors
Many are exposed but few develop PTSD
Ratio of 3:1
•Categories of Risk Factors
•Trauma
•Peri-and post-trauma events
•Individual Characteristics
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
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)
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
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
Classical Conditioning
Triple vulnerability
Generalized Biological Vulnerability
Generalized Psychological Vulnerability
Experience of Trauma
True Alarm
(or intense basic emotion – anger, distress)
Learned Alarm
(or strong mixed emotions)
Anxious Apprehension
(focused on re-experiencing emotions)
Advance or Numbing or Emotional Response
Moderated by Social Support and Ability to Cope
PTSD
Concern about CC
•Startle responses
•Reexperiencing
•Nightmares
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
Treatment
•Combination Treatments
•E+AMT+ CR eg CPT
•CBT
•TF-CBT
•DBT
•“Power Therapies:” TIR, VK/D, EMDR – (concern?)
•ACT
•Interapy
•VRE
•Pharmacotherapy
Pharmacotherapy
Challenge
multiple rather than single neurobiological systems
Assumption
Brain Circuitory
Excessive activation of
Amygdala
Target Systems
•Adrenergic
•HPA
•Serotonergic
•Dopaminergic
Disinhibition of
Amygdala
Recurrent fear conditioning of
ambiguous stimuli perceived as
threatening
Medication
Antidepressants
•SSRI – sertraline, paroxetine, fluoxetine
•TCA – amitriptyline, desipramine
•MAOI - phenelzine
Antiadrenergic
•prozasin
Antikindling
•Carbamazepine
•Atypical antipsychotic
•resperidone, quetiapine, olanzapine
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)
Limitation
• Cultural issues
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.