Transcript Diagnostic criteria for PTSD

Post Traumatic
Stress Disorder
Acute Stress
Disorder
Dr. A. Hadjebi
History
 U. S. civil war : Soldier's heart syndrome
 1900 s : Traumatic neurosis due to the
influence of psychoanalysis
 World war I : shell shock
 World war II : combat neurosis or
operational fatigue
 Vietnam war : post traumatic stress
disorder
History
 PTSD: DSM-III (1980)
 ASD; DSM-IV (1994)
 PTSD in DSM-III: reexperience(1),psychic
numbing(2), other items(1), no duration
criteria
 PTSD in DSM-III-R is similar to DSM-IV-TR
 In ICD-10 PTSD & ASD are stress related
disoders
Epidemiology
 Life time prevalence (8%)
 30% of Vietnam veterans
 25 % subclinical form of disorder
 In women : life time prevalence 10- 12%
 In men : life time prevalence 5- 6%
 PTSD is most prevalent in young adults
 Men's trauma : combat experience
 Women's trauma : assault or rape
Epidemiology
 PTSD most likely to occur in single ,
divorced , widowed , socially withdrawn ,
low socioeconomic level
 First degree biological relatives of
persons with a history of depression
have an increased risk for developing
PTSD following a traumatic event
Comorbidity
 About 2/3 having at least tow other disorders
 Common comorbid conditions include :
depressive disorders , substance related
disorders , other anxiety disorders and bipolar
disorders
Etiology
 Stressor
 Risk factors
 Psychodynamic factors
 Cognitive – behavioral factors
 Biological factors
Noradrenergic system
Opioid system
Corticotropin – releasing factor and the
HPA axis
Psychological aspects of
PTSD
 Emotional response to trauma reminder
 Base line physiological activity
 Exaggerated startle reflex.
Diagnostic criteria for PTSD
 Exposure to a traumatic event
 The traumatic event is persistently
reexperienced
 Persistent avoidance of stimuli associated
with the trauma
 Persistent symptoms of increased arousal
 Duration of the disturbance is more than 1
month
Diagnostic criteria for PTSD
 Significant distress or impairment in
social, occupational or …
 Specify if : acute : < 3 months
chronic : > or = 3 months
 With delayed onset
Diagnostic criteria for ASD
The disturbance last for a min. of 2 days
and a max. of 4 weeks and occurs within
4 weeks of the traumatic events
PTSD in children and
adolescents
 Child risk factors include :
- demographic factors ( age,
socioeconomic status )
- life events
- psychiatric comorbidity
- parental psychopathology
- parental marital status
Gulf war syndrome
 Health problems
- Irritability
- Chronic fatigue
- Shortness of breath
- Muscle and joint pain
- Migraine headaches
- Digestive disturbances
- Rash
- Hair loss
- Forgetfulness
- Difficulty concentrating
Differential diagnosis
organic; head trauma, epilepsy,
alcohol use disorder
 Pain disorder
 Substance abuse
 Other anxiety disorders
 Mood disorders
 Borderline disorders
 Dissociative disorders
 malingering
Course and prognosis
30 % recover completely
40 % mild symptoms
20 % moderate symptoms
10 % remain unchanged
 Good prognosis is predicted by :
- rapid onset of the symptoms
- short duration of the symptoms
- good premorbi functioning
- strong social supports
- absence of other psychiatric, medical or
substance – related disorders
Course and prognosis
 The very young and very old have more
difficulty with traumatic events than do
these in midlife
 PTSD that is comorbid with other disorders
is often more severe and perhaps more
chronic and difficult to treat
 Social support influence the development,
severity and duration of PTSD
Treatment
 Psychotherapy
 Pharmacotherapy
Psychotherapy
 Psychodynamic psychotherapy
 Cognitive – behavior therapy
 Group therapy
 Family therapy
pharmacotherapy
 SSRIs : Sertraline and Paroxetine
 Buspirone
 TCA: Impramine, Amitriptyline
 Some studies indicate that pharmacotherapy
is more effective in treating the depression,
anxiety and hyperarousal than in treating the
avoidance and emotional numbing
 Other drugs ; MAOIs ( Phenelzine ),
Trazodone, Anticonvalsants, (carbamazapine,
valpoarate ), clonidine, propranolol
Recommendation
 Strongly recommend selective serotonin
reuptake inhibitors (SSRIs) as first line
agents for the treatment of PTSD.
 Recommend tricyclic antidepressants
(TCAs) and monoamine oxidase inhibitors
(MAOIs) as second-line treatments for
PTSD.
 Consider an antidepressant therapeutic trial
of at least 12 weeks before changing
therapeutic regimen.
Recommendation
 Consider prazosin to augment the
management of nightmares and other
symptoms of PTSD.
 Recommend medication compliance
assessment at each visit.
 Since PTSD is a chronic disorder,
responders to pharmacotherapy may need to
continue medication indefinitely; however it is
recommended that maintenance treatment
should be periodically reassessed
Group
Name
Global Reexp. Avoid. Hypera
imp.
rousal
SSRI
Fluoxe
tine
Sertrali
ne
Paroxe
tine
*
*
*
*
*
TCAs
*
*
MAOIs
*
*
*
*
*
*
*
*
*
Group
Name
Global Reexp. Avoid. Hypera
imp.
rousal
Sympa
tholytic
*
Prazosi
n
*
*
Propran
olol
Novel
Antidep.
Trazod.
*
*
*
Nefaz.
*
*
*
Group
Name
Global Reexp. Avoid. Hypera
imp.
rousal
Antico
nvul.
CBZ
*
*
Valpro.
*
BDZ
Atyp.a
ntipsy.
*
*
*
*
Special considerations on
sep. 11. 2001
 3500 deaths and injuries
 45% of adults reported symptoms of stress
, such as distressing recollections of the
event, insomnia, nightmare,…
 90% reported minor degrees of symptoms
 Susceptibility to symptoms was associated
with : female, nonwhite, having previous
psychological illness, being close to
disaster site
Special considerations on
sep. 11. 2001
 Over 80 % of parents reported that their
children had one or more symptoms
 Survey of Manhattan residents
conducted 5 to 8 weeks after the world
trade center collapsed:
- 9.8% (90000 ) people had PTSD or
clinical depression
- 3.7% ( 34000 ) people met the criteria
for both diagnosis