Transcript Post-Traumatic Stress Disorder: An Update in the Wake of 9-11

Anxiety Disorders
Anita S. Kablinger MD
Associate Professor, Departments of
Psychiatry and Pharmacology
LSUHSC-Shreveport
DSM-IV Anxiety Disorders
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Specific phobias
Panic disorder
Agoraphobia
Generalized anxiety disorder
Social phobia
Obsessive-compulsive disorder
PTSD
PTSD: Presentation Outline
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Introduction/History
Clinical Presentation/DSM-IV Criteria
Differential Diagnosis
Etiology/Risk Factors
Treatment Issues
Prevention
Introduction/History
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First appeared in DSM-III (1980)
Recognized by Shakespeare in Henry IV
Civil War descriptions
WWI- shell shock and soldier’s heart
WWII- operational fatigue and combat
neurosis
• Organic origin vs psychogenic derivation
Diagnostic Criteria for PTSD
• A. Exposed to traumatic event
– The person experienced, witnessed, or was
confronted with an event involving actual or
threatened death, serious injury or a threat to
physical integrity of self or others
– The person’s response involved intense fear,
helplessness or horror
Diagnostic Criteria for PTSD
• B. The traumatic event is reexperienced in
one or more of the following ways
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Recurrent images, thoughts or perceptions
Recurrent distressing dreams of the event
Acting or feeling as if the event was recurring
Intense psychological distress OR physiologic
reactivity at exposure to cues that symbolize or
resemble an aspect of the event
Diagnostic Criteria for PTSD
• C. Persistent avoidance of stimuli associated with
trauma and numbing as indicated by 3 or more:
– Avoiding thoughts, feelings, or discussion, activities,
places or people that bring back recollections; sense of
foreshortened future
– Inability to recall; restricted affect
– Diminished interest or participation
– Feeling detached or estranged
Diagnostic Criteria for PTSD
• D. Persistent symptoms of increased arousal by 2
or more:
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Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
• E. Duration for more than 1 month
Diagnostic Criteria for PTSD
• F. Clinically significant impairment in functioning
• Acute: Less than 3 months
• Chronic: Greater than or equal to 3 months
• With delayed onset: Onset at least 6 months after
the stressor
Diagnostic Criteria for Acute
Stress Disorder
• A: Exposed to traumatic event
• B. Experiences three or more of:
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Subjective sense of numbing, detachment
Reduction in awareness of surroundings
Derealization
Depersonalization
Dissociative amnesia
• C. Persistent reexperiencing of the event
Diagnostic Criteria for Acute
Stress Disorder
• D. Marked avoidance of stimuli that arouse
recollections of the trauma
• E. Marked symptoms of anxiety or
increased arousal
• F. Causes significant impairment
• G. Lasts 2 days to 4 weeks and occurs
within 4 weeks of the trauma
Epidemiology
• Prevalence of PTSD: 1-14% community, 358% in at-risk populations
• 25-30% lifetime prevalence in Vietnam
veterans
• 85% in concentration camp survivors
• May be modulated by cultural differences
• All ages; individuals or groups; F>M
Differential Diagnosis
• Mental disorder secondary to GMC
– (ex. head injury)
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Substance-induced disorder
Dissociative disorders
Major depressive episode
Borderline personality disorder
Malingering
Etiological Factors
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Magnitude of the stress exposure
Cognitive appraisal factors
Intense fear or helplessness predictive
Sympathetic hyperactivity
Psychological factors
– psychodynamic
– cognitive
– behavioral
Examples of Traumatic Events
• Violent crime
• Sexual trauma
• Chronic physical
abuse
• Military combat
• Natural disasters
• Manufactured
disasters
• Complicated or
unexpected
bereavements
• Accidents
• Captivity
Risk Factors
• Lack of social support
• Family psychiatric
history, esp. anxiety
• Previous psychiatric
history
• Certain personality
traits
• Early separation of
parents
• Parental poverty
• Abuse in childhood
• Childhood behavioral
problems
• Limited education
• Adverse life-events
prior to trauma
• Female
Six Strongest Predictors of
Trauma Exposure
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Male
Absence of college education
Extroversion
Neuroticism
Early misconduct
Family psychiatric illness
Six Strongest Predictors
for Risk of PTSD
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Female
Neuroticism
Early separation from parents
Prior anxiety or depression
Familial anxiety
Familial antisocial personality disorder
Associated Symptoms Important
for Treatment
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Survival and behavioral guilt
Somatic distress
Paranoia
Interpersonal alienation
Vegetative changes of depression
Hopelessness
Impulsivity
Course and Prognosis
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30% recover completely
40% continue with mild symptoms
20% moderate symptoms
10% unchanged or worsen
Startle, nightmares, irritability and
depression often worsen with age
• Comorbidity is high (MDD, OCD, Panic,
substance abuse)
Treatment: ASD
• Talking about the trauma allowing:
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confrontation
acceptance
process
integration
• Individual or group therapy, hypnosis
• Followed by support and superficiality
Treatment: PTSD
• Requires multiple modalities
• Initial education, support and referrals
important to establish trust
• Pharmacotherapy
• Psychotherapy
• Relaxation Training
Treatment: PTSDPharmacotherapy
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Duration of at least 8-12 weeks
Adequate dosages
Maintenance treatment for at least 1 year
Antidepressants
Mood stabilizers
Propranolol, clonidine
Atypical antipsychotics
Drug Treatment of PTSD
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Amitriptyline
Fluoxetine
Sertraline*
Paroxetine*
Propranolol
Clonidine
Valproic Acid
Carbamazepine
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50-300 mg/day
20-60
50-200
20-50
40-160
0.2-0.6
750-1,750
200-1,200
Drug Treatment of PTSD
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Lithium
Quetiapine
Risperidone
Olanzapine
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300-1,500 mg/day
25-700
0.5-6
2.5-20
Treatment: PTSDIndividual Psychotherapy
• Crisis Intervention
– establish rapport, promote acceptance
– educate, attend to general health
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Trauma-focused psychotherapy
Implosive therapy
Systematic desensitization
Hospitalization may be necessary at times
Points to Remember
• If a patient has multiple complaints, think
PTSD or personality disorder up front
• Under-detected because we don’t ask the
right questions
• One of the few DSM disorders defined by
it’s cause!
DREAMS
Detachment
Re-experiencing the event
Emotional effects
Avoidance
Month in Duration
Sympathetic hyperactivity or hypervigilance
PTSD Questionnaire
DSM-IV Anxiety Disorders
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Specific phobias
Panic disorder
Agoraphobia
Generalized anxiety disorder
Social phobia
Obsessive-compulsive disorder
PTSD