Transcript Posttraumatic Stress Disorder

Posttraumatic Stress Disorder
Epidemiology of PTSD
• Kessler et al. (1995) Posttraumatic Stress
Disorder in the National Comorbidity Study
• Representative National Sample
– N = 5877 AGE 15-54 Years old
– Lifetime prevalence of PTSD is 7.8%
– More than 1/3 of people with an initial episode
of PTSD fail to recover after 10 years
Kessler National Comorbidity
• Women: Most Common Experiences
– Rape
– Sexual Molestation
– 50% had experienced a trauma that met DSM-IV
stressor criterion
• Men: Most Common Experiences
– Combat
– Witnessing death or severe injury
– 60% had experienced an event that would meet DSMIV stressor criterion
Kilpatrick et al (1992)
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Nationally representative sample
4008 women
13% reported a completed rape
Of those who were raped
– Lifetime PTSD 32%
– Current PTSD 12%
Prevalence of PTSD
• 5th Most Common Psychiatric Condition
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Major Depression
Attention-deficit/hyperactivity disorder
Specific phobia
Social phobia
Comorbidity
• PTSD/Depression: Nearly 50% Comorbid
• Specific phobia, social phobia, and
dysthymic disorder also prevalent
• Male PTSD/Alcohol Abuse: (52%)
Criterion A: Exposure Criteria
• Experienced or Witnessed an Event that
involved actual or threatened death or
serious injury or a threat to physical
integrity
• Person’s response involved fear,
helplessness, or horror or in children
agitated behavior
Criterion B: Re-experiencing
Criteria
• Recurrent and Intrusive distressing
recollections of the event (images, thoughts,
or repetitions)
• Recurrent distressing dreams of the event
• Acting or feeling as if the traumatic event
were recurring
Criterion B continued…
• 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
Criterion C1: Persistent
Avoidance Criteria
• 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
Criterion C2: Numbing of Gen.
Responsiveness Criteria
• Markedly diminished interest or
participation in significant activities
• Feeling of detachment or estrangement from
others
• Restricted range of affect
• Sense of foreshortened future
Criterion D: Increased Arousal
Criteria
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Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Criterion E
• Symptoms in criteria B, C, and D are more
than 1 month
Criterion F
• The disturbance causes significant distress
or impairment in social, occupational, or
other important areas of functioning
Specifications
• Acute: if duration of symptoms is less than
3 months
• Chronic: if duration of symptoms is 3
months or more
• With delayed onset: if onset of symptoms
is at least 6 months after the stressor
Green’s Generic Dimensions to
Stressors
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Threat to one’s life
Threat to bodily integrity
Severe physical harm/injury
Exposure to grotesque
Witnessing/learning of violence or severe harm to
others
• Learning of exposure to a noxious agent
• Causing death or severe harm to another
Dohrenwend
• National Veterans Readjustment Study
– Congressional Mandate in 1983
– Representative sample of 1632 US Vietnam Theater
Veterans and matched sample of 716 Vietnam era
veterans and 668 civilian comparison
– NVVRS rates for Male VTV 30.9% lifetime
And 15.2% current
CDC rates reported 14.7% lifetime and 2.2% current all 11 to 12
years after the Vietnam war ended
Dohrenwend contd.
• National Veterans Readjustment Study
– Perplexing in these relatively high rates of PTSD was
the relatively low rates of ‘combat’
– Used data from archival sources to develop a record
based military historical measure for exposure
– Impairment wasn’t formerly a part of the criteria
– Adjusted Rates for impairment and verification are
• 18.7% lifetime and 9.1% current
• Dose response relationship between combat and exposure
Cultural Factors and PTSD
• Hispanic veterans report significantly higher rates
of PTSD than AA or Caucasian veterans.
Hypotheses include:
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Greater exposure to war zone stressors
Greater prewar vulnerability
Culturally driven differences in reporting symptoms
Different post war stressful events
Greater experiences with racial/ethnic prejudice and
discrimination
Sample
• Subsample NVVRS
– 94 Majority White
– 70 African American
– 84 Hispanic (Mostly Mexican American (63), Puerto
Rican (15), Latin American (6)
• War Zone stressor severity measured
• Peri- and Post-War Discrimination
• Vulnerability Factors Measured
– Younger age at entry to Vietnam
– Lower Armed Forces Qualification Tests
– Disciplinary Actions
– Pre-Vietnam educational level
– Pre war psychiatric disorder
Results
• Both Blacks and Hispanics had higher rates of
war-related first onsets of PTSD (current PTSD
10-11 years after the war)
• PTSD course was more chronic for Hispanics than
Blacks
• Hispanics experiences more war-zone stressors
compared with Caucasians
• Controlling war zone exposure did not account for
the greater rates of PTSD in Hispanics
• Prewar vulnerability factors emerged as important:
younger age, less education, lower AFQT scores
9/11
• Explored stressor exposure and PTSD symptoms
in 11,037 adults who live south of Canal Street in
NYC on 9/11 (lower Manhattan)
• PTSD Checklist Civilian Version
• Within disaster exposure, e.g., residential
proximity, direct exposure intensity (caught in the
dust cloud from the tower collapse, an occupant of
the north or south tower, sustaining an injury,
witnessed horror, seeing people fall or jump from
the buildings)
9/11 Results
• 43.6% reported reexperiencing, 20.4%
reported avoidance, 38.6% reported
hyperarousal
• Most common symptoms were
hypervigilance, being upset by reminders,
and insomnia
• Current PTSD prevalence 12.6%
9/11 Results: Bivariate results
• Increased risk was reported for African Americans, Hispanics, and
other nonAsian minorities (Asian race was protective)
• Increased risk for women
• Lower education and lower income was associated with increased risk
• Older age and female gender was assoc with increased risk
• Being divorced, separated or separated was associated with increased
risk
• Within disaster risk factors were sustained injury, witnessed horror
exposure to dust cloud, being in a building that was damaged or
destroyed (except WTC towers), living less than 1000 feet from the
towers
• Post disaster risk was associated with evacuation from one’s home and
involvement in rescue/recovery efforts.
9/11 Results: Multivariate results
• Risk for PTSD increased for all age groups relative to the
younger groups (greatest risk for adults 45-64 years);
• Increased risk for women
• Risk for PTSD higher among Hispanics, African
American, and other ethnicities
• Divorced, widowed or separated continued to increase risk;
• Lower education and income was associated with
increased risk
• Exposure intensity remained as a significant risk factor
• Evacuation and involvement in rescue recovery efforts
remained
Confluence of Factors
• Discuss findings in terms of the diathesis,
personality, stress model
Acute Stress Disorder
Criterion A: Exposure Criteria
• Experienced or Witnessed an Event that
involved actual or threatened death or
serious injury or a threat to physical
integrity
• Person’s response involved fear,
helplessness, or horror or in children
agitated behavior
Criterion B: Dissociative Criteria
• Subjective sense of numbing, detachment,
or absence of emotional responsiveness
• Reduction in awareness of one’s
surroundings (e.g., “being in a daze”)
• Derealization
• Depersonalization
• Dissociative amnesia
Criterion C: Re-experiencing
Criteria
• Recurrent images
• Thoughts, dreams, illusions
• Flashback episodes, or a sense of reliving
the experience
• Distress on exposure to reminders of the
traumatic event
Criterion D: Avoidance Criterion
• Marked avoidance of stimuli that arouse
recollections of the trauma (e.g., thoughts,
feelings, conversations, activities, places,
people)
Criterion E: Physiological
Criteria
• Marked symptoms of anxiety or increased
arousal (e.g., difficulty sleeping, irritability,
poor concentration, hypervigilance,
exaggerated startle response, motor
restlessness)
Criterion F: Psychosocial Criteria
• Clinically significant distress or impairment
in social, occupational, or other important
areas of functioning
• Impaired ability to pursue some necessary
task, such as obtaining personal assistance
or mobilizing personal resources
Criterion G: Time Criteria
• Minimum of 2 days
• Maximum of 4 weeks
• Occurs within 4 weeks of the traumatic
event
Inter-relationship between ASD
and PTSD
Event
ASD
2 days –
4 weeks
PTSD
4 weeks
and on
How does someone develop
PTSD?
Classical Conditioning
CS
Unconditioned
Stimulus
Car
Jacking
Unconditioned
Response
Thoughts
Feelings
Behaviors
CR
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
Model for PTSD
• PTSD develops through the process of
classical conditioning
• When cues are encountered, anxiety and
other emotional reactions increase. Over
time, habituation would occur.
• Avoidance maintains PTSD because
habituation can never occur.
– Negative Reinforcement