Posttraumatic Stress Disorder

Chaired by Dr Siddharth Shetty

Introduction
spontaneous re-experiencing of aspects of the traumatic events, startle responses, irritability, impairment in concentration and memory, disturbed sleep, distressing dreams, depression, phobias, guilt, psychic numbing, and multiple somatic symptoms.

Clinicians have long known that traumatic events can produce psychiatric symptoms in many people. At the end of the 19th and the beginning of the 20th centuries, railway disasters, the World Wars, and the Holocaust prompted systematic descriptions of these symptoms associated with traumatic stress reactions Variety of labels to describe including fright neurosis', combat/war neurosis', shell-shock', survivor syndrome', and nuclearism'.

Whether the traumatic event - considered a major cause of these symptoms? Charcot, Janet, Freud, and Breuer suggested that hysterical symptoms were caused by psychological trauma, but not widely accepted. Dominant view - traumatic event in itself was not a sufficient cause of post-trauma symptoms, and experts searched for other causes. Many suspected an organic cause.

railway spine syndrome damage to the spinal cord shell shock microsections of exploded bombs entering brain camp survivors starvation and brain damage

compensation neurosis malingering and compensation-seeking

predominant view was that reactions to traumatic events are transient.

chronic symptoms

pre-existing neurotic conflicts, or mental illness, unstable personalities

recognition of the long-standing psychological problems of many war veterans, especially Vietnam veterans, changed this view and convinced clinicians and researchers even people with sound personalities can develop clinically significant psychological symptoms if they are exposed to horrific stressors Planned for the inclusion of a post-Vietnam syndrome diagnosis in the DSM-III recognized that traumatic events such as combat, rape, man-made or natural disasters also give rise to a characteristic pattern of psychological symptoms. This prompted the introduction of post-traumatic stress disorder (PTSD) as a diagnostic category in DSM-III.

Definition
An anxiety disorder comprising 3 clusters (re-experiencing, avoidance/numbing, and increased arousal) of symptoms that can develop following a person's exposure to a traumatic event. Unusual : Criteria specifies an etiological event.(Exposure to a traumatic stressor) Central focus in PTSD concerns preoccupation with threats that occurred in the past. A disorder driven by pathogenic memories of past danger.

The Paradigm Shift in the Concept of PTSD

original view was that PTSD was a normal response to an abnormal stressor Destigmatizing victims, this view placed the causal burden squarely on the trauma by the 1990s, it became obvious that most people exposed to qualifying traumatic events did not succumb to PTSD. Transient symptoms of acute distress were common, but PTSD was not. Resulted in paradigm shift in the conceptualization of PTSD. No longer was it a normal response to an abnormal stressor; it was now viewed as a psychopathological response to an extreme stressor

Importance of Traumatic stressor

The diagnostic criteria specify the experience of a traumatic event as a necessary condition for the diagnosis Occurs always as a direct consequence of acute severe stress or continued trauma. The stressful event is the primary and overriding causal factor, and the disorder would not have occurred without its impact.

What makes a stressor traumatic? In everyday language, many upsetting situations are described as traumatic', for example divorce, loss of job, or failing an exam a field study designed showed that only 0.4 per cent of a community sample developed PTSD in response to such low magnitude' stressors. Few people would contest that horrific events such as rape or bombings are traumatic to capture the essence of these stressors, DSM-IIIR required a traumatic stressor to be outside the range of usual human experience' and that it would be markedly distressing to almost anyone DSM-IIIR definition appeared too restrictive, epidemiological studies showed that stressors that can lead to PTSD are actually quite common, for example road traffic accidents

DSM IV dropped the notion stressor must be outside the range of usual human experience as being ambiguous and gave a specific definition. On the basis of research findings, specified that threat to life or physical integrity to self or others during the event is one of the most consistent predictors of PTSD Also included the person's subjective response to the situation as an additional criterion, involving intense fear, helplessness or horror (or disorganized or agitated behaviour in children) definition of trauma is broadened in DSM IV TR. No longer must one be the direct recipient or even witness of trauma; merely learning about a threat to others now qualifies.

ICD-10 uses a broader definition and characterizes traumatic stressors by their exceptional severity and the distress they would cause for the average person. Thus, the ICD-10 diagnosis refers to a common-sense understanding of which situations are likely to be extremely distressing

ICD 10 Stressor Criterion 1. Event or situation of exceptionally threatening or catastrophic nature

ICD 10 DCR A. 1. Event or situation of exceptionally threatening or catastrophic nature

DSM IV TR A.1. 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 (or) learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate 2. the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

2. Likely to cause pervasive distress in almost anyone

2. Likely to cause pervasive distress in almost anyone

Debate still exists :?Include further possible emotional responses ?Perpetrators of crime also develop PTSD Feelings of shame & guilt at the time/subsequently. ?emphasis on threat to life/physical integrity omit dimensions of subgroups of traumatic items Mental defeat , perceived loss of all autonomy(politicians).

Expanding trauma concept - difficult to elucidate psychobiological mechanisms mediating symptom expression as it increases the heterogeneity among those qualifying for the diagnosis. More we broaden trauma concept - the less plausibly ,we can impute causal significance to the stressor itself & must emphasize vulnerability factors in etiology. risk factors move into the causal foreground whereas the stressor recedes into the background

Epidemiology
Mainly large scale studies in US ,Australia. National Comorbidity Survey Replication, 6.8% Americans develop PTSD at some point in their lives. In fact, most epidemiological studies - 8 to 12% of the U.S. population will develop PTSD at some point in their lives (lifetime prevalence) and Between 1 and 3% will have the disorder in any given year (annual prevalence). Prevalence - twice as great in women as in men, despite the fact that men are more exposed How common is Trauma? Kessler et al DSM IIIR 60.7%M & 51.2%W Stein et al DSM IV -81.3%M , & 74.2%W Most common Sudden death of loved person What types of Trauma? Rape 65%M,46%W Kessler et al High rates combat exposure, childhood neglect, physical abuse, sexual molestation Low rates accidents, witnessing death/injury,natural disasters

What proportion develop PTSD? Kessler et al -8%M,20%W Breslau et al 13%M, 30% W Bias overestimation as pts reported on worst trauma experienced (DSM IV 9%) Retrospective methodology Comorbidity? PTSD shows a substantial comorbidity with affective disorders, other anxiety disorders, substance-use disorders, and somatization 88%M,78%W Kessler et al Is PTSD primary or secondary to the comorbid diagnoses? PTSD was primary to comorbid affective or substance-use disorders in the majority of cases, and PTSD was primary to comorbid anxiety disorders in about half of the cases

SUMMARY OF EPIDEMIOLOGICAL STUDIES

Majority experience atleast 1 traumatic event in lifetime. In assessing PTSD history, interviewers should probe for specific events. Assault(esp sexual) & combat higher impact Sudden unexpected death of loved one & RTAs imp causes Men traumatic ,women impact events Women twice likely to develop PTSD -10-12% vs 5-6% Comorbid depression, substance use disorders appear secondary to PTSD

Etiology
Risk Factors Unlike risk for most psychiatric disorders, risk for PTSD entails two steps: Risk for exposure to traumatic events, and risk for PTSD among those exposed to traumatic events Risk factors for being exposed to trauma: less than a college education, being male, having a history of childhood conduct problems, having a family history of psychiatric illness, being more extroverted, and being more neurotic

Among those exposed to trauma, risk factors for PTSD include: being female, neuroticism, lower social support, lower intelligence quotient (IQ), pre-existing psychiatric illness (especially mood and anxiety disorders), family history of mood, anxiety, or substance abuse disorders, and neurological soft signs (e.g., nonspecific abnormalities in central nervous function). recent work has shown that previous exposure to trauma heightens the risk for PTSD in response to subsequent trauma only if the person develops full-blown PTSD in response to the earlier trauma i.e. early trauma per se does not heighten the risk for PTSD in response to later trauma.

Biological processes Genetics

Twin studies: to determine the relative contributions of heredity, shared environment, and unique environment to variance in PTSD symptoms MZ twins were more concordant than were DZ twins as much as one third of the variance in PTSD symptoms is associated with genetic variance, whereas the remainder is chiefly associated with unique environmental experiences (e.g., intense combat.) Studies- genetic influence on vulnerability for PTSD: above-average cognitive ability seems to protect against PTSD among those exposed to trauma

Chronic stress reaction several abnormalities that are consistent with a chronic stress reaction or an enhanced reactivity to minor stressors chronically enhanced secretion of adrenaline (epinephrine) and noradrenaline (norepinephrine). enhanced startle responses and higher baseline heart rates and blood pressure than traumatized controls without PTSD. Hypothalamicpituitaryadrenal axis abnormalities abnormally low levels of cortisol show a very different pattern of hypothalamicpituitaryadrenal response than patients with major depression. low dose of dexamethasone, PTSD patients exhibit hypersuppression of cortisol hypothalamicpituitaryadrenal axis in PTSD is characterized by enhanced negative feedback- set to produce large responses to further stressors.

Neuroendocrinological abnormalities downregulation of the a2-adrenergic receptors lead to enhanced locus coeruleus activity and increased levels of noradrenaline. This could cause the symptoms of autonomic hyperarousal and re-experiencing Yohimbine (which blocks the a2-receptors) provokes flashbacks and panic attacks in a substantial subgroup of PTSD patients. sensitized serotonergic system. respond to meta-chlorophenylpiperazine with panic attacks and PTSD symptoms such as flashbacks Endogenous opiates have been suspected to mediate the symptoms of emotional numbing and amnesia enhanced levels of corticotrophin-releasing factor (CRF) in their cerebrospinal fluid compared to normal controls increased levels of thyroid hormones with the severity of hyperarousal symptoms.

Neuroimaging reduced hippocampal volume lead to enhanced reactivity to stimulation, and may be involved in the deficits in autobiographical memory observed in PTSD patients risk factor? Or consequence? dysfunctions in the amygdalae or the areas that project to them (the hippocampus, septum, and prefrontal cortex), leading to problems in the extinction of fear responses to reminders of the traumatic event Animal models of PTSD animal model of inescapable shock Inescapable shock leads to changes in the noradrenergic system, the HPA axis, and endogenous opiates that parallel findings in PTSD patients re-experiencing of the traumatic event may constitute a kindling process, to the effect that PTSD symptoms become more easily triggered with time overconsolidation (long-term potentiation) of the trauma memory

Psychodynamic factors : The subjective meaning of a stressor may determine its traumatogenicity. Traumatic events can resonate with childhood traumas Reactivation of a previously quiescent, yet unresolved psychological conflict. Somatization , alexithymia - the after-effects of trauma. Common defenses used include denial, repression, minimization, splitting (childhood sexual trauma), dissociation, and guilt (as a defense against underlying helplessness).

Psychological processes
Fear conditioning Mowrer's two-factor conditioning theory of phobias has been applied to PTSD. Classical and operant conditioning Nature of trauma memories deficits in their autobiographical memories of the traumatic event, organization of the autobiographical memory base in general may be affected. Patients with PTSD have difficulty retrieving specific autobiographical memories and exhibit overgeneral memories, similar to depressed patients. These memory deficits may be linked to poor problem-solving and enhanced stress responses to everyday stressors, a sense of foreshortened future (because the overgeneral memory of the past makes it difficult to envisage a future), and more frequent stimulus-driven retrieval of memories of the traumatic event leading to re-experiencing symptoms.

peritraumatic responses and negative symptom appraisals peritraumatic dissociative responses, such as feeling disconnected from one's body or feeling as if events were occurring in slow motion, predict later PTSD. negative interpretations of one's acute responses can predict whether someone develops PTSD. if trauma victims interpret their exaggerated startle responses and nightmares as indicative of personal weakness or misconstrue, flashbacks as indicative of impending psychosis Behaviours that maintain PTSD symptoms Whereas many people will recover from initial PTSD symptoms, some do not get better avoidance of reminders, suppression of thoughts and memories connected to the event, rumination, safety behaviours, dissociation, and the use of alcohol or drugs

Diagnosis and Clinical Features

Unlike many syndromes in DSM-IV-TR, symptoms of PTSD are characterised by theoretically meaningful functional interrelations exposure to a trauma establishes a pathogenic memory manifested as reexperiencing symptoms. Recurrent intrusions of the memory, in turn, motivate responses of victims to avoid stimuli likely to trigger these involuntary rememberings of trauma. symptoms of increased arousal may result from either the direct consequences of traumatic fear conditioning or from recurrent re-experiencing symptoms It is the memory of the traumatic stressor that unites the otherwise disparate symptoms of PTSD into a coherent syndrome

PTSD in children : Distressing dreams of eventnightmares (monsters,rescue,threats) Reliving repetitive play Diminished interest in activitiesreports from parents,teachers Sense of foreshortened future Omen formation Stomachaches,headaches

ICD10

ICD-10 emphasized the causal role of traumatic stressors in producing psychological dysfunction even more clearly, in that a specific group of disorders, reaction to severe stress, and adjustment disorders', was created

ICD 10
Stressor Criterion 1. Event or situation of exceptionally threatening or catastrophic nature 2. Likely to cause pervasive distress in almost anyone

ICD 10 DCR
A. 1. Event or situation of exceptionally threatening or catastrophic nature 2. Likely to cause pervasive distress in almost anyone

F43.1 Post-traumatic stress disorder

Symptom criteria Necessary criteria 1. Repetitive intrusive recollection or reenactment of the event in memories, daytime imagery, or dreams Necessary symptom B. Persistent remembering or reliving of the stressor in intrusive flashbacks, vivid memories, or recurring dreams, and in experiencing distress when exposed to circumstances resembling or associated with the stressor C. Actual or preferred avoidance of circumstances resembling or associated with the stressor which was not present before exposure to the stressor D.1 Inability to recall either partially or completely, some important aspects or the period of exposure to the stressor

Other typical symptoms 2. Sense of numbness and emotional blunting, detachment from others, unresponsiveness to surroundings, anhedonia 3. Avoidance of activities and situations reminiscent of trauma Common symptoms 4. Automatic hyper arousal with hypervigilance, enhanced startle reaction, insomnia 5. Anxiety and depression

Rare symptoms 6. Dramatic acute bursts of fear, panic, or aggression triggered by reminders

or 2. Persistent symptoms of increased psychological sensitivity and arousal(not present before exposure to stressor), shown by any two of the following a) Difficulty in falling or staying asleep b) Irritability or outbursts of anger c) Difficulty in concentrating d) Hypervigilance e) Exaggerated startle response

309.81 Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present: (1) 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 (2) 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 re-experienced in one (or more) of the following ways: (1) 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. (2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. (3) 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 on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, fee lings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that a rouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities (5) feeling of detachment or estrangement from others (6) restricted range of affect (e.g., unable to have loving feelings) (7) 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 two (or more) of the following: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hyper vigilance (5) exaggerated startle response E. Duration of the disturbance (symptoms in Criteria B, C, and 0 ) is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of fu nct ioning. Specify if: Acute: if durat ion of symptoms is less than 3 months Chronic: if duration of symptoms is 3 mont hs or more Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

ICD 10 vs DSM IVTR

1. Different definitions of the qualifying stressor 2. Additionally, DSM requires that the person's response to traumatic event involved intense fear, helplessness, or horror, a criterion added to validate the psychological seriousness to the person of the exposure to the trauma. 3. The diagnostic algorithms, while similar, are also not congruent. 4. ICD requires that in most cases, symptoms have their onset within 6 months of the stressor (if onset > 6 months, considered probable). In contrast, DSM has no such requirement and provides a specifier to indicate delayed onset (>6mo) 5. DSM IV requires that the symptoms persist for at least one month and provides an acute/ chronic specifier for a duration of less than/ more than 3 months. ICD10 has no such requirement.

Course and prognosis

symptoms usually begin immediately after the trauma. Delayed onset in a minority (11%) 50% recover, 50%- chronic Longitudinal course varies : Permanent recovery Unchanging mild fluctuation More obvious fluctuation Deterioration with age Chronic PTSD may be associated with increased rates of adverse physical outcomes, including musculoskeletal problems & cardiovascular morbidity Factors affecting recovery : Recovery environment Facilitated by social support Hindered by ve responses of people, stress caused by long lasting ve effects of event. Psychological processes Impeded by excessive negative appraisals Maladaptive behaviours- avoidance, denial, thought suppression,rumination

Differential Diagnosis
Duration of symptoms Acute stress reaction (immediate reaction in 1st 3 days after event) Acute stress disorder (symptoms upto 4 wks) Type of stressor, Symptom pattern Adjustment disorders (less severe) Enduring personality change after a catastrophic experience (extreme,prolonged stress at least for 2 yrs) Intentional content OCD (current and future threats) GAD (envisioning & worrying about threats that lie in the future ,different situations and concerns) Specific phobias only avoidance symptoms Panic disorders - occur unexpectedly and spontaneously Dissociative disorder (1st 4 weeks)

Mood disorder or other anxiety disorder (symptoms (+) before stressor) Others with perceptual alterations Schizophrenia and other psychotic disorders Delirium Substance use disorders GMC producing psychosis

Assessment
Scales Gold standard Clinician-Administered PTSD Scale (CAPS) Structured Clinical Interview for DSM-IV-TR Diagnostic Interview Schedule Structured Interview for PTSD Self rated Davidson Trauma Scale Short PTSD Rating Instrument PTSD Checklist PK scale on the Minnesota Multiphasic Personality Inventory Mississippi Scale for Combat-Related PTSD Impact of Events Scale (I,A,H) PTSD Scale

Children & adolescents : Direct observation, structured interview, self-report measures, collateral informants (e.g., parent and teacher reports), behavioral analysis of pre- and posttrauma functioning. CAPS for children Nader 1994 Conners Parent Rating Scale and Conners TeacherRating Scale assess externalizing symptoms Childrens Depression Inventory assess internalizing symptoms

TREATMENT
1) 2) 3) 4) 5) 6) Goals To reduce intrusive symptoms To reduce avoidance symptoms To reduce numbing and withdrawal To dampen hyperarousal To reduce psychotic symptoms when present To improve impulse control EARLY INTERVENTION Psychological debriefing- reduce acute distress in survivors ,prevent subsequent psychiatric morbidity. Effort to depathologize and destigmatize. Most recommend against compelling people to engage group cathartic experiences. Screen, watch, and wait policy

PHARMACOTHERAPY SSRIs ,SNRIs 1st line drugs efficacy, tolerability, safety ratings Sertraline,paroxetine officially indicated Venlafaxine extended release on trial TCAs - Imipramine,amitriptyline 8 weeks adequate trial Risk of relapse if discontinued - significant Other drugs : Trazodone,Mirtazapine MAOIs Phenelzine Mood stabilizers Carbamazepine,valproate , lamotrigine Atypical antipsychotics Olan,Risp,Quit enhancing sleep, reducing aggression(short term) Adrenergic inhibitors Prazosin , Propranolol Few double blind trials to suggest efficacy.

PSYCHOTHERAPY Trauma focused psychological treatments : Meta analysis most effective psychological treatment 1. CBT Exposure imaginal exposure/reliving Cognitive therapy 2. Eye movement desensitization & reprocessing (EMDR) Series of rapid & rhythmic eye movements while pt focuses on trauma related image, emotions,sensations ,thoughts 3. Others Anxiety management Anger management program Psychodynamic therapy Hypnotherapy Supportive therapy Group therapy Family therapy

NICE guidelines
Early interventions Watchful waiting Immediate psychological interventions for all- debriefing Interventions where symptoms are present within 3 months of a trauma Trauma focused CBT Interventions where symptoms have been present for more than 3 months after a trauma - Trauma-focused psychological treatment (trauma-focused CBT or EMDR) 8-12 sessions Drug treatments Do not offer drugs as routine first-line treatment for adult PTSD sufferers in preference to trauma-focused psychological therapy. General use: paroxetine or mirtazapine Specialist use: amitriptyline or phenelzine

Children and young people Interventions in the first month after a trauma Trauma focused CBT Interventions more than 3 months after a trauma Trauma focused cognitive behavioural therapy adapted appropriately.

DSM V
Trauma- death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in 1/more of the following ways: 1.Experiencing the event(s) him/herself 2.Witnessing the event(s) as they occurred to others 3.Learning that the event(s) occurred to a close relative or close friend 4.Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse) New D criterion dividing C criterion Negative alterations in cognitions and mood that are associated with the traumatic event(s) E2. New criterion-Focus on reckless and self-destructive behavior Acute vs Chronic deleted because of lack of evidence supporting such distinctions

CONTROVERSIES
1.Defining the stressor criteria clearly 2.Homogenity of PTSD criteria Recent research emphasizes more on person`s subjective response to event Culturally defined symptoms e.g flashbacks Diversity in prevalence Diagnostic overlap (ASD vs PTSD) Recall bias Malingering ( to get compensation) Co-occurrence of PTSD other psychiatric disorders Primary vs secondary Unitary / spectrum concept ?

FUTURE IMPLICATIONS
To further delineate the basis for trauma related symptoms Further research: To refine the stressor criteria To include severity criteria for symptoms rather than counting the presence of symptoms

Thank U