Transcript PTSD: Defining the Disorder

PTSD: Defining the Disorder
Alyssa Rippy PhD.
Program Coordinator PRRC Program
Jack C. Montgomery VAMC outpatient clinic
Feb. 27th, 2014
Prevalence of Traumatic Stress
• Historically people viewed trauma very
differently
• Currently, many people do not expect sudden
catastrophic events to happen to them
• Many people live with daily stress or
occasionally intense stress
• Serious trauma is unexpected and more rare
Prevalence of Traumatic Stress
• The majority of people do experience at least one
traumatic stressor and a large number experience
more than one
• Prevalence is the number of persons in a
population who have been victimized, could be in
a year or across the lifetime
• For every 1000 age 12 or older:
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2 rapes
2 assaults with injury
5 robberies (US National Crime Victimization Survey 1995)
16,272 murders in US in 2008
Prevalence of PTSD
• Prevalence samples have focused on rates of
PTSD among trauma exposed individuals
• Breslau et al., (1991) estimated a lifetime
prevalence rate of 9% for PTSD (6% of men
and 11% of women developed PTSD)
• Resnick et al., (1993) found 7% or trauma
exposed sample had PTSD at some point
• Women are more likely than men to develop
PTSD
Prevalence of PTSD
• The most likely traumatic events are the very
events that result in less PTSD (>10%)
• Violent, personal trauma resulted in greater
prevalence of PTSD with rape resulting in the
single most likely to cause PTSD
Classifying Reactions to Stress and
Trauma
• People exhibit a range of
symptoms in response to stress
that typically are temporary
• Chronic stress may result in
negative beliefs about
helplessness or about the cause
of the situation
• May develop into depression,
substance abuse or an anxiety
disorder
• When stress decreases, so do the
symptoms
Prevalence of Traumatic Stress
from Kessler et. Al., (1995)
Trauma
Men %
Women %
Rape
1**
9**
Molestation
3
12*
Physical Attack
11
7*
Combat
6*
0
Shock (trauma to another)
11
12
Threat with weapon
19
7
Accident
25
14
Disaster
19
15
Witness
36
15
Neglect
2*
3
Physical Abuse
3*
5*
Other Trauma
2
3*
Factors Predisposing a Person to Stress
 Some individuals are more likely to develop long-term
problems under stress than others
 Coping skill and other resources are key
 Some individual characteristics that improve an individual’s
ability to cope with stress
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Optimism
Greater psychological control or mastery
Increased self-esteem
Good social support
 Genetic factors may also be at play
 Recent research links a particular form of the 5HTTLPR gene was linked
to how likely people were to developing depression especially with two
short forms of the gene
 May make us more “stress sensitive”
Characteristics of Stress
 What makes one stressor more serious than another?
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The severity of a stressor
Its chronicity
Its timing
How closely it affects our own lives
How controllable it is
 Stressors that involve the more important aspects of a
person’s life tend to be highly stressful for people
 The longer a stressor operates, the more severe its
effects
 Encountering a number of stressors at the same time
also makes a difference
Classifying Reactions to Stress and
Trauma
• Exposure to trauma may create more dramatic stress
responses
• Sudden, unexpected, threatening events
• Bodies are hard-wired for emergency
• Triggers biological, cognitive, and emotional responses
• Autonomic nervous system/fight or flight/freezing or
disassociating
• In attempts to cope with symptoms people may try to
shut off the images and feelings, too much avoidance
can lead to prolonged reactions that can evolve into
PTSD
Recovery and Chronicity
• Longitudinal studies have examined victims of
crime and PTSD
• Very strong reactions initially with gradual
recovery over the months that follow
• 3 months post crime 47% with PTSD
• Most improvement 3-9 months
• Women with more severe reaction and stopped improving
after 1 month developed PTSD
• Rape victims had more severe reaction than assault victims
• sooner improvement with therapy
Posttraumatic Stress Disorder (According
to new DSM-V)
• Criterion A:
• Exposure to actual or threatened death, serious injury, or
sexual violence in one (or more) of the following ways:
• Directly experiencing the traumatic events
• Witnessing, in person, the event as it occurred to others
• Learning about the traumatic events occurred to a close family
member or close friend. In cases of actual or threatened death of a
family member or friend, the event must have been violent or
accidental
• Experiencing repeated or extreme exposure to aversive details of the
traumatic event (e.g. first responders collecting human remains;
police officers repeatedly exposed to details of child abuse)
• NOTE: Criterion A4 does not apply to exposure through electronic
media, television, movies, or pictures unless this exposure is work
related
Posttraumatic Stress Disorder
Criterion B: Presence of 1 or more of the following intrusion
symptoms associated with the traumatic event, beginning
after the traumatic events occurred:
1. Recurrent, involuntary, and intrusive distressing memories
of the trauma (in children older than 6, repetitive play
which themes or aspects of the trauma are expressed)
2. Recurrent distressing dreams of the event
3. Dissociative reaction (flashbacks) in which the individual
feels or acts as if the traumatic events were recurring.
4. Intense psychological distress at exposure to internal or
external cues that resemble an aspect of the trauma
5. Psychological reactivity on exposure to internal or external
cues that resemble an aspect of the trauma
Posttraumatic Stress Disorder
Criterion C Persistent avoidance of stimuli associated
with the traumatic events, beginning after the
traumatic event occurred, as evidenced by one or
both of the following:
1. Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with
the traumatic events
2. Avoidance of or efforts to avoid external reminders
(people, places, activities, objects, situations) that
arouse distressing memories, thoughts, or feelings
about or closely associated with the trauma
Posttraumatic Stress Disorder
Criterion D: Negative alterations in cognitions and mood associated with
the traumatic events, beginning or worsening after the traumatic events
occurred, as evidenced by two or more of the following:
1. Inability to remember an important aspect of the traumatic events
2. Persistent and exaggerated negative beliefs or expectations about
oneself, other, the world
3. Persistent, distorted cognitions about the cause of consequences of the
traumatic events that lead the individual to blame himself/herself or
others
4. Persistent negative emotional state (anger, guilt, shame)
5. Markedly diminished interest or participation in significant activities
6. Feelings of detachment or estrangement from others
7. Persistent inability to experience happiness, satisfaction, or loving
feelings
Posttraumatic Stress Disorder
Criterion E: Marked alterations in arousal and reactivity associated with the
traumatic events, beginning or worsening after the traumatic events
occurred, as evidenced by 2 or more of the following:
1. Irritable behavior and angry outbursts (with little or no provocation)
typically expressed as verbal or physical aggression toward people or
objects
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance
Posttraumatic Stress Disorder
Criterion F: Duration is more
than 1 month
Criterion G: The disturbance
causes significantly
significant distress or
impairment in social,
occupational, or other
important areas of
functioning
Adjustment Problems
• Following a trauma people
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may avoid situations they may have previously enjoyed
Have strong emotional reactions
Irritability that affects relationships
Numbing down
May become more violent with others
Substance abuse (3/4 lifetime Veterans with PTSD)
Work adjustment
Divorce and parenting problems
Unemployment
Legal issues
Stress Related Illness
• PTSD = increased health care
utilization
• More visits to primary care
• Association btw domestic
violence, illness, and medical
utilization (Veterans also)
• Hypertension
• Stress related medical issues
Comorbidity
• IN addition to PTSD, other
disorders might develop
due to maladaptive
coping
• 88% of men and 79% of
women had comorbid
disorders
• Most common are
depression (53-78%)and
substance abuse (5384%), and anxiety
disorders (30-56%)
Long-term Effects of PTSD
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PTSD can be a severe and chronic condition
“Walking Disorder”
Symptoms of PTSD can be delayed
Survivor guilt and moral injury
Comorbid disorders
• Substance abuse 80%
• Depression
• Anxiety disorders
• Traits that mimic personality disorder including
Antisocial PD
• Psychotic symptoms including paranoia
Social Influences on Reactions and
Recovery
• How people are treated after a trauma may
well affect how they recover
• How others respond to one’s trauma can
greatly influence how victims interpret the
events and whether they continue to share
their experiences and reactions or withdraw
and isolate themselves
• Social support may reflect pre-existing
influences as well as pot-trauma responses
Social Support
• Knowing you have
people supportive of
you that you can talk to
or knowing there is no
one close to you that
you trust and you have
to try to handle it alone
Life Survival Skills
• After returning from combat, many soldiers
feel physically revved up and hyperalert after
returning home
• They react to situations at home as if they are
in a warzone
• High levels of anger
Returning Home
• The mind remembers skills that served to
keep it alive
• Reflex actions/reactions
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Reacting to loud noises
Crowds
Traffic
Not being able to communicate with someone
Having things moved
Using aggression to get things done
Remaining armed and ready
How the Brain Reacts to Stress
• Anger
• Emotional control through numbing or detachment is
necessary under extreme stress
• In combat soldiers learn to turn off emotions other
than anger
• Anger helps a soldier to survive
• Anger is conditioned in basic training as a way of
getting things done
• Wreaks havoc with family and loved ones once soldiers
return home
How the Brain Reacts to Stress
• Cognitive Problems
• Veterans and deployed soldiers often complain of
difficulty concentrating and paying attention
• One of the symptoms of PTSD but also is due to
increased adrenaline and so can occur in those without
PTSD
• Memory, attention, and concentration all become
oriented toward survival, and this can make it difficult
to stay focused on other things after returning home
How the Brain Reacts to Stress
• Control
• Control is an essential survival skill
• Survival in a combat zone depends on the ability to
react instantaneously with the correct sequence of
combat tasks under fire (remember the loading of guns
in the civil war)
• If this fails the mission could fail and get someone killed
• This can cause difficulty with loved ones when they do
not follow through with what they were going to do or
move things unexpectedly
What can you do?
• Hoge gives some very basic and effective ways of reducing stress
and anger
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Relaxation
Journaling
Acceptance
Exercise
Relaxation
Healthy diet
Sleep medication/medication for nightmares
Staying away from alcohol and drugs
Medications
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Antidepressants (Trazodone)
Melatonin
BP meds
Antipsychotics (Seroquel)
Benzodiazepines (Xanax, Vlium, Ativan, Librium)
Zolpidem (Ambien)
Dealing with Stressful Situations
• Learning to deal with triggers is a big part of
any treatment for PTSD
• Numerous things can trigger anxiety, fear, and
anger or result in the sudden flooding of
images and feelings
• Avoidance creeps in
• This can result in trouble with loved ones who
want to go places or enjoy activities that are
being avoided
How to Tell the Story and Who to Tell it
To
• Individuals with PTSD have to find their own way to
tell their story whether by writing it down or talking to
someone
• Pastor, Psychologist, spouse, friend, battle buddy
• Warriors often want to protect those closest to them
• Important for families to know that they may not be
able to share some stories with them
• Sharing with fellow warriors may be a problem
especially where alcohol is involved, can result in the
group getting ramped up
• Need to tell the story in a place that is free from
judgment you emotions can be experienced freely