Transcript Definition of TBI

Post Traumatic
Stress Disorder
David A. Brady, D.O.
Midlothian, Virginia
Anxiety

Anxiety is a normal reaction to stress. It
helps us deal with stressful situations,
makes us more aware, increases focus
and concentration.
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Anxiety becomes a problem when it
becomes an excessive, irrational dread
of a situation, event, or object.
Anxiety Disorders
There are five major types of anxiety
disorders. Each has different
symptoms but all symptoms cluster
around excessive, irrational fear, and
dread.
1.
2.
3.
4.
5.
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder
Posttraumatic Stress Disorder
Social Phobia (Social Anxiety Disorder)
Relevance
Lifetime prevalence of PTSD is 1% - 15%
in the U.S. population.
[In high-risk groups, such as combat veterans and
victims of violent crimes, prevalence ranges from 3% to
58%.]
Relevance

PTSD is more prevalent among war veterans
than among any other group.

The National Vietnam Veterans Readjustment
Survey reports that approximately 25% of U.S.
veterans, men and women, were suffering from
PTSD in the early 1990s.
Traumatic Events
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War
Mugging
Rape
Torture
Kidnapping
Held captive
Child abuse
Accidents (work
related, MVA)
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Acts of terror
Train wrecks
Ship wrecks
Air plane crashes
Bombings
Natural disasters
Medical Procedures
(Surgeries, ICU / CCU
Stays, Chemotherapy,
Burn Treatments)
Posttraumatic Stress Disorder
 “The complex somatic, cognitive, affective
and behavioral effects of psychological
trauma.”
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It is characterized by intrusive thoughts,
nightmares and flashbacks of past
traumatic events, avoidance of reminders,
hypervigilance, and sleep disturbance,
which lead to social, occupational and
interpersonal dysfunction.
Posttraumatic Stress Disorder
“Neurobiological research has helped us
to understand that PTSD is not an
“emotional” or “psychological” disorder,
but a physiological condition that effects
the entire body, including cardiovascular
functioning, hormone system balance,
and immune functioning.”
Hoge
Posttraumatic Stress Disorder

Many people exposed to trauma will
experience distress with similar symptoms
associated with PTSD.

PTSD is a subset of people who are
significantly impaired of a period of time
greater than 1 month.
Epidemiology
Lifetime prevalence 6.8-12.3 percent
 Estimated 11 to 17 percent of US veterans
returning from active duty in Afghanistan and Iraq
 Onset at any age
 Females > males (4X more likely to develop sx)
 Susceptibility may run in families
 Associated with drug and alcohol abuse and/or
dependence
 Look for one or more of the other anxiety disorders
 PTSD is associated with increased median annual
health care costs (38 to 104%)
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Epidemiology
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Risk factors
 Lack of social support = dissociation associated with
the trauma
 Extent of injury is strongly correlated with PTSD
(those in combat)
 Lower socioeconomic status
 Parental neglect
 Family or personal history of psychiatric illness
 Initial severity of reaction to traumatic event
 Previous exposure to trauma
Pathophysiology
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Unclear pathophysiology
MRI studies have shown decreased hippocampal volume in
patients with PTSD.
Increased central norepinephrine levels with down-regulated central
adrenergic receptors, chronically decreased glucocorticoid levels
with up regulation of receptors.
Hemispheric lateralization
Abnormalities in amygdala
 exaggerated response of the amygdala, resulting in impaired
regulation by the medial prefrontal cortex
 patients with PTSD have diminished activation of the medial
prefrontal cortex during the processing of fear
Insufficient cognitive resources to engage appropriate cognitive
strategies
Clinical Presentation
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Marked cognitive, affective, and behavior
responses to stimuli, leading to flashbacks, severe
anxiety and fleeing or combative behavior.
Individuals compensate by avoiding triggers and
generally shutting down.
Emotional numbing and diminished interest in
everyday activities with detachment from others.
Sense of a foreshortened future
Psychiatric comorbidity is high:
 Depression, anxiety, substance abuse, and
somatization disorders
Anger / Irritability
“Anger is an emotion, an immediate
internal reaction to a situation.”
 “A problem in our society, and in the
approach to anger “management”, is that
anger - the emotion - is often confused with
other responses.”
 “It is not the anger that needs managing,
but the various behaviors that can arise
from it.”

Hoge
Flashbacks
Flashbacks consist of images, sounds,
smells, or feelings triggered by ordinary
events (Examples: car backfires, door
slams).
Nightmares
Problems With Authority
Loss of Faith
Bias and Hate
Symptoms
“Every “symptom” included in the
definition can also reflect normal
responses to life-threatening events
or the normal way the body
responses to extreme stress.”
Hoge
Symptoms
Symptoms are usually worse if the
traumatic event was triggered by
another person (examples: rape, terror,
mugging, direct contact in war).
Mental Status Exam
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General appearance may be affected (disheveled / poor personal
hygiene).
Behavior may be altered. Agitated, extreme startle reaction.
Orientation is sometimes affected. The patient may not know the
current place or time.
Patients may report forgetfulness, especially concerning the
specific details of the traumatic event.
Concentration is poor.
Impulse control is poor.
Speech rate and flow may be altered.
Mood and affect may be changed. Patients may have feelings of
depression, anxiety, guilt, and/or fear.
Patients may be more concerned with the content of
hallucinations, delusions, suicidal ideation, phobias, and reliving
the experience. Certain patients may become homicidal.
Diagnosis
6 categories:
1. Subjective and objective components of
exposure to trauma
2. Reexperiencing of the trauma
3. Persistent avoidance of the trauma
4. Increased arousal
5. Duration > 1 month
6. Disturbance causes social and
vocational impairment…
DSM IV criteria
A.
(1)
(2)
The person has been exposed to a traumatic event in which both
of the following have been 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 person's response involved intense fear, helplessness, or horror. Note: In
children, this may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently reexperienced in one (or more)
of the following ways:
(1)
(2)
(3)
(4)
(5)
recurrent and intrusive distressing recollections of the event, including images,
thoughts, or perceptions. Note: In young children, repetitive play may occur in
which themes or aspects of the trauma are expressed.
recurrent distressing dreams of the event. Note: In children, there may be
frightening dreams without recognizable content.
acting or feeling as if the traumatic event were recurring (includes a sense of reliving
the experience, illusions, hallucinations, and dissociative flashback episodes,
including those that occur upon awakening or when intoxicated). Note: In young
children, trauma-specific reenactment may occur.
intense psychological distress at exposure to internal or external cues that symbolize
or resemble an aspect of the traumatic event.
physiological reactivity on exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event.
DSM IV Criteria
C. Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the
trauma), as indicated by 3 or more of the following:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
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
markedly diminished interest or participation in significant activities
feeling of detachment or estrangement from others
restricted range of affect (e.g., unable to have loving feelings)
sense of a foreshortened future (e.g., does not expect to have a career, marriage,
children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as
indicated by 2 or more of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1
month.
F. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Imaging in PTSD
MRI studies of the brain suggest that the
amount of hippocampal atrophy correlates with
the intensity of PTSD symptoms, but MRI is still
not a recommended diagnostic test. Some
studies in monozygotic twins show that a small
hippocampus may be a predisposing factor to
the later development of PTSD in the face of a
stressor.
 Amygdala
hyperactivity combined with
hippocampal atrophy seems to be
consistent with diagnosis of PTSD.
 TBI
that has destroyed amygdala function
will prevent PTSD.
Screening
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PTSD checklist
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PCL-M or the PCL-C
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Clinician Administered PTSD Scale
(CAPS)
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SPAN (Startle, Physiological Arousal,
Anger, and Numbness)
Differential Diagnosis
Acute stress disorder
Traumatic Brain Injury
Adjustment disorder
Malingering (must be excluded)
Mood disorder with or without psychotic features
Psychotic disorders caused by a general medical condition
Substance induced disorders
Implications in Primary Care
The diagnosis of PTSD can be missed in a
primary care setting, as patients
frequently present with somatic
complaints or depression and are often
reluctant to discuss their traumatic
experiences.
Treatment of PTSD
Treatment of PTSD
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Treatment is often best accomplished with a combination of
pharmacologic and nonpharmacologic therapies.
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Medications may be required to control the physiological symptoms,
which can enable the patient to tolerate and work through the highly
emotional material in psychotherapy.
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SSRI’s are first choice in medical management
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Prazosin for nightmares
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Atypical antipsychotics
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If present, alcohol or substance abuse problems should be the
initial focus of treatment
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Hyperarousal symptoms can be treated with B-blockers
Treatment of PTSD
Exposure Therapy
Group Therapy
Support Groups
Don’t insult the patient
Never tell the patient: Don’t talk about your
trauma, talk about your feelings…
 Virtual Reality
 Sexual Issues (psychological and
physiological)
 Physical Issues
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Treatment of PTSD
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Don’t forget the forgotten (spouses,
children, mothers, fathers, brothers, sisters,
friends, neighbors, ministers, healthcare
providers…)
Close medical follow-up
Exercise
Recreation
Routine (Sleep)
Vocational Rehabilitation
Education
Spiritual Issues
Prognosis
PTSD is a chronic condition with 1/3 of
patients recovering at one year and 1/3
symptomatic at 10 years…
“I hold it to be a fundamental truth of
human nature, that when someone
withholds something traumatic it can cause
great damage. When you share something
with someone it helps to place it in
perspective, but when you hold it inside, as
one of my students once put it, “it eats you
alive from the inside out.” Furthermore,
there is great therapeutic valve in the
catharsis that comes with lancing these
emotional boils. The essence of
counseling is that pain shared is pain
divided…”
Grossman
The
End